Common Insurance Questions

“Does having dental insurance mean there will be no charge for a dental visit?” 

Dental Insurance is designed to help you offset the cost of your dental care and to help you maintain good overall oral health. That’s why we focus on preventive care to catch signs and symptoms of dental disease early. This could reduce the chance that you will need more complex treatment later. Dental insurance is more like a discount card to help offset costs; it isn’t something that will cover everything after a deductible is met. Diagnostic & preventative care (Cleanings) are typically covered up to twice a year at 100%. Like your medical insurance, a co-pay, annual deductible, and plan limits apply to all other dental services.

“Greenlake Kids Dentistry is out-of-network for my Insurance Carrier; what does this mean?

Greenlake Kids Dentistry accepts most major insurance plans, regardless of in or out-of-network status. Being “in-network” with an insurance carrier means we have signed a contract to offer “Member Rates” to the patients who subscribe to that Carrier’s insurance plan. These rates are lower than our standard fees. Patients with in-network insurance plans may have better coverage and lower out-of-pocket costs than patients with out-of-network insurance plans. Check with your carrier for in vs. out-of-network coverage tables.

“If twice-yearly cleanings are typically covered, why have I received a charge for my child’s last cleaning?”

Some diagnostic & preventative services such as x-rays or fluoride (which is applied as part of cleaning to help prevent tooth decay) are sometimes only partially covered or covered once per year by some insurance plans. In this case, expect to pay a small fee ($32-63) for fluoride or your contracted co-insurance percentage for other diagnostic services.

“How can I avoid billing surprises for future appointments” 

To ensure timely billing and surprise payments, we recommend that all families take 5 minutes before their child’s next dental visit to review their Dental Insurance coverage.  This information is easily accessed on your carrier’s website or app. Even if you have been with the same employer and had the same dental coverage for years, the benefits & coverage or even the member ID number can change yearly! Keeping our office updated with any member ID changes ensures billing is quick and accurate.

To avoid billing surprises, we are happy to provide a treatment plan estimate for future appointments upon request. This outlines the estimated out-of-pocket cost for future appointments. We, at no time, guarantee what insurance will or will not cover each claim. We can only assist in estimating the portion of the cost due for our services.

“Why was my claim declined?”

Once an insurance claim has been filed, your insurance carrier will provide an Explanation of Benefits (EOB) statement. This statement details the amounts covered for each procedure and the remaining amount the patient may be responsible for. In the case of a declined claim, the EOB from your insurance carrier lists the reason/s.  Our office receives an electronic copy of this statement, and insurance payments are applied to the patient ledger. We are not responsible for providing an Explanation of Benefits to the patient. If the patient is responsible for payment, we will send an account statement within 30 days of the service date. If your claim is declined, it will be noted on your next statement.  Unfortunately, our staff is not able to research every partially paid or declined claim. Questions regarding declined claims or coverage amounts should be directed to your insurance carrier. 

“Why did the Greenlake Kids Dentistry charge more for a procedure than the insurance company allows”

You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist’s actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist’s fee has exceeded the usual, customary, or reasonable fee (“UCR”) used by the company. A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable or well above what most dentists in the area charge for a certain service. This can be very misleading and is not accurate.

Insurance companies set their own schedules, and each company uses different fees they consider allowable. These allowable fees may vary widely because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily chooses a level they call the “allowable” UCR Fee. Frequently this data can be three to five years old, and the insurance company sets these “allowable” fees so they can make a net 20%-30% profit. Unfortunately, insurance companies imply that your dentist is “overcharging” rather than saying they are “underpaying” or their benefits are low. The less expensive insurance policy will generally use a lower usual, customary, or reasonable (UCR) figure.