Understanding Your Insurance

UCR charges are the maximum allowable amounts that will be covered by the plan. Although these terms make it sound like a UCR charge is the standard rate for dental care, it is not. The terms “usual,” “customary,” and “reasonable” are misleading for several reasons:

• Insurance companies can set whatever amount they want for UCR charges. They may not match the current actual fees charged by dentists in a given area.
• A company’s UCR amounts may stay the same for many years. They do not have to keep up with inflation or the costs of dental care.
• Insurance companies are not required to say how they set their UCR rates. Each company has its own formula.

If your dental bill is higher than the UCR, it does not mean your dentist has charged too much. It could mean your insurance company has not updated its UCR charges. It could also mean that the data used to set the UCR is taken from areas of your state that are different from yours.

This is the largest dollar amount a dental plan will pay during the year. Your employer decides the maximum levels of payment in its contract with the insurance company. You are expected to pay copayments and any costs above the annual maximum. Annual maximums are not always updated to keep up with the costs of dental care. If the annual maximum of your plan is too low to meet your needs, ask your employer to look into plans with higher annual maximums.

The plan may want you to choose dental care from its network of preferred providers. The term “preferred” means these dentists have a contract with the dental benefit plan; it does not mean these are dentists the patient prefers. If you get dental care from a dentist who is not in the network, you may have higher out-of-pocket costs. Learn about your plan’s costs when using both in- and out-of-network dentists.

A dental plan may not cover conditions that existed before you enrolled in the plan. For example, benefits will not be paid for replacing a tooth that was missing before the effective date of coverage. Even though your plan may not cover certain conditions, you may still need treatment to keep your mouth healthy.

These terms apply to patients covered by more than one dental plan. The benefit payments from all insurers should not add up to more than the total charges. Even though you may have two or more dental benefit plans, there is no guarantee that all of the plans will pay for your services. Sometimes, none of the plans will pay for the services you need. Each insurance company handles COB in its own way. Please check your plans for details.

A dental plan may limit the number of times it will pay for a certain treatment. But some patients may need a treatment more often to maintain good oral health. For example, a plan might pay for teeth cleaning only twice a year even though the patient needs a cleaning four times a year. Make treatment decisions based on what’s best for your health, not just what is covered by your plan.

Many dental plans state that only procedures that are medically or dentally necessary will be covered. If the claim is denied, it does not mean that the services were not necessary. Treatment decisions should be made by you and your dentist.

If your plan rejects a claim because a service was “not dentally necessary,” you can appeal. Work with your benefits manager and the plan’s customer service department to appeal the decision in writing.

• Bundling– Claims bundling is when two different dental procedures are combined by the insurance company into one procedure. This may reduce your benefit.
• Downcoding is when a dental plan changes the procedure code to a less complex or lower-cost procedure than was reported by the dental office.
• Least Expensive Alternative Treatment (LEAT) – Your plan may have a LEAT clause. That means that if there is more than one way to treat a condition, the plan will pay for only the least expensive treatment. However, the least expensive option is not always the best. For example, your dentist may recommend an implant for you, but the plan may only cover less costly dentures. You should talk with your dentist about the best treatment option for you.