Why Doesn't My Insurance Cover This?

March 7, 2017

I already pay for dental insurance, why do I have to pay more?

 

Your insurance benefit information is very important to understand for many reasons, including making sure that you have purchased an insurance plan that is best for you and using your insurance for optimal benefit coverage. However, benefit information can be difficult to read and understand completely, especially as benefits vary from plan to plan as well as insurance company to insurance company.

 

Here at Hintz Family Dentistry, we want to make sure that you understand what you are covered for, what you are not covered for, and to what percentage is your portion to pay. It is important to realize that most dental benefit plans do not cover all dental procedures.

 

The role of Hintz Family Dentistry is to assist you with quality dental care and, as a service to you, file claims to your dental plan. Whatever your insurance company does not pay on this claim is your responsibility. There are several reasons why your dental plan will not pay on a claim, including: 

 

  • Your annual maximum has been met.

This means that the maximum amount that your dental plan will pay for the year has been depleted. Patients are responsible for copayments and any costs that exceed this maximum. This maximum is reset at the beginning of the next benefit year. If you receive dental insurance through an employer, your employer decides the annual maximums and copayment levels.

  • Your dental office is not considered a preferred provider.

There are dental plans that require patients to only see certain dental offices. Depending on whether a dental office is considered in-network or out-of-network with your dental plan, which means that the dental office is (or is not) in contract with that dental plan, your copayments, deductibles, maximums, and any other special considerations could vary.

  • Pre-existing conditions.

Some dental plans have a dental insurance rider called "Missing Tooth Clause." This means that your dental plan may not cover conditions that existed before you enrolled in the plan, like replacing a tooth that was missing before the effective date of coverage with your current insurance.

  • Plan frequency limitations.

Your dental plan may limit the number of times it will pay fora particular treatment over a certain amount of time. For example, a full panoramic x-ray is usually covered once every 5 years.

  • Coordination of benefits.

This occurs if you have more than one active dental plan. Even though you have multiple dental plans, there is no guarantee that you will not have a copay; it all depends on the benefit information on each of the dental plans and how each insurance company handles coordination of benefits.

 

If you have questions about your insurance, you can contact your employer's Human Resources department, your insurance company, or we are always available for your questions.

 

The content on this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of qualified health providers with questions you may have regarding medical conditions.