Patients, Providers and Insurance…. Oh My

Dental Insurance Colorado Springs

Are you in-network with my insurance?

We hear this question daily. While it is a very important question to ask there is so much more to your insurance then us being in-network with them. We are in-network with all PPO insurance plans. PPO means preferred provider organization.  Being a PPO provider means we have agreed to provide care for patients at a certain rate. Accepting these PPO insurance plans does not dictate what your provider diagnoses. However, it does mean that by using the PPO insurance plan the patient receives a discount on our services. Every 24 months we re-credential with these PPO plans. Being a preferred provider allows us to see and treat patients referred to us. 

How does my dental insurance actually work? 

Each year a patient is given a maximum allowed amount that insurance will pay to providers. This maximum is per person and typically ranges from $1000-$2500, though some plans are higher. While all insurance companies have this allowable amount they still do not pay 100% for all things.  Most insurance companies follow a 100/80/50 base plan. 100% for Diagnostic and Preventive (Cleanings, Exams, and X-rays) 80% for basic services (Fillings, Perio cleanings, Root Canals) and 50% for major services (Dental Crowns, Dentures, and Implants). This is the most common breakdown we see. However, each dental insurance company has hundreds of different employer and self-pay group plans that can all be different. 

“Why won’t my insurance pay more?’

When giving out a pre-treatment estimate we can never guarantee that your insurance company is going to pay all, some, or none of the treatment diagnosed by your provider. When getting a breakdown of benefits your insurance company tells us first that all breakdowns are an estimate and cannot be guaranteed until treatment is complete, a claim is received, and a dental consultant has reviewed the claim. Most claims are straightforward and insurance pays them. Other claims take time and appeals if necessary.  As a courtesy, we send these claims on the patient’s behalf. Each basic and major claim is sent with a doctor’s narrative, x-rays, and any dates pertaining to the treatment.  Once submitted to insurance it is out of our hands-on how or if they pay. Once insurance has decided whether they will pay on claims you will receive an explanation of benefits. It is very important to know that this EOB is not a bill. It is simply an explanation of what your insurance company paid and what the patient portion is for the services rendered by your provider. Insurances do not dictate the treatment preformed only the price a patient pays. 

“What do you mean my insurance does not cover that procedure?”

There are times where insurance will not cover a procedure due to different exclusions.  Each insurance plan has its own form of exclusions and can vary from group to group. One reason treatment can be denied is a waiting period. A waiting period is a time period that insurance will not pay for any basic or major services. Typically a waiting period lasts 12 months from the time the insurance plan became effective. Another exclusion could be a missing tooth clause.  This clause means that if a tooth was missing prior to the effective date your insurance will not cover a restoration on that tooth. An implant or bridge restoration could be denied if your tooth was missing prior to your insurance plan.  The most common exclusion is a frequency limitation. Most plans only pay for a certain number of procedures during any given period. Cleanings and exams are usually covered 2 in 12 months or 2 in a calendar year. Crowns and dentures are typically covered 1 in a 5-year period. 

We are here to help.

Knowing how your PPO dental plan works are key with any dental treatment diagnosed and performed. There are many insurance companies, Delta Dental of all 50 states, MetLife, United Health Care, United Concordia Federal- Tricare- Employer-based, Cigna, and Aetna just to name a few. We see hundreds of different group plans a year and while our front office staff is very well versed in insurance knowledge it is ultimately the responsibility of the patient to know what their plan covers.  Each appointment our front office staff researches the basics of your insurance plan to give the most accurate estimate we can make. If we have questions we call your insurance company to get the most information we can. We ask that if you are confused about something ask us or even call your insurance. If you are in the market for a new dental insurance plan we can help answer any questions and give you a list of questions that you will want answers to. We are all here and willing to help you understand. 

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