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The purpose of dental insurance is to help individuals by paying for a portion of the cost of their dental
care. Most dental benefit plans consist of a contract between an employer and an insurance company. For
are determined by the type of plan chosen by you and/or your employer.
Unlike medical insurance plans, no dental insurance plan that we know of pays 100% of all dental
procedures. However, many patients are under the impression that their plan does pays 90%-100% of all
dental fees. We find that the average dental plan usually pays 50%-80% of the average total fee. The
amount paid is usually determined by how much you or your employer has paid for coverage or the type of
contract your employer has set up with the insurance company.
What does the term: "Usual, Customary and Reasonable fees" mean?
Often your dental insurer will reimburse you at a rate that is lower than the dentist's actual fee. This fee is
not based on what a dentist actually charges, but what each dental insurance company wishes to cover.
Frequently, insurance companies state that the reimbursement was reduced because "your dentist's fee
has exceeded the usual, customary, or reasonable fee (UCR)." 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 simply
is not accurate.
Each insurance company sets it's own payment schedule and "allowable fees." In most cases, the
allowable fees are set about 30% below actual industry standard and do not take into consideration the
fees charged by dental specialists (Pediatric Dentists, Orthodontists, Endodontists, etc.) These allowable
fees may vary widely between insurance companies and are determined so that the insurance companies
can make the profit they need in order to operate. In general, a less expensive insurance policy will use a
lower usual, customary, or reasonable (UCR) fee schedule. Dentists are not allowed to know what the UCR
or maximum allowable fees are for any procedure. In addition, insurance companies are not required to
disclose to the consumer, or the dental profession how they determine these fees.
Why didn't the insurance company cover my child's treatment?
One of the most frustrating issues to deal with is when an insurance company disregards standard
treatment that has been recommended by both the ADA and the American Academy of Pediatric Dentistry.
We occasionally see dental plans that do not cover standard, recommended procedures such as dental
sealants, topical fluoride application and even white "tooth colored" fillings. Since we do not have
information on the hundreds of dental plans available, the patients ends up being responsible for knowing
what exclusions and limitations are included in their plan.
Orthodontic Dental Insurance:
We will initially assist you with filing your claim for orthodontics to ensure that you receive your maximum
insurance benefit. A typical plan might cover 50 percent of the costs of braces up to $1,500-$2,500. Each
insurance company has it's own schedule for reimbursing subscribers for orthodontic treatment. Some
plans pay the subscriber periodically throughout the course of treatment, while others reimburse the
patient in full at the beginning of treatment. Most plans reimburse the patient monthly, based on the
monthly payment plan you have set up with our orthodontic office.
Because of the various types of reimbursement schedules, we require our patients to pay our office
directly for orthodontic services. Most patients select one of the convenient, monthly, no interest, payment
plans offered by our office.
PPOs and Private Insurance Networks:
We do not participate in, nor are we members of any organized dental insurance network, such as Delta
Dental. Many of our patients have this type of insurance and we assist them by filing their claims.
Generally, these programs will not reimburse our office directly, but rather, reimburse the patient. In these
cases, we ask that you pay for services the day of your appointment. Generally, most insurance carriers
process and pay claims to the subscriber within 2-3 weeks.
care. Most dental benefit plans consist of a contract between an employer and an insurance company. For
are determined by the type of plan chosen by you and/or your employer.
Unlike medical insurance plans, no dental insurance plan that we know of pays 100% of all dental
procedures. However, many patients are under the impression that their plan does pays 90%-100% of all
dental fees. We find that the average dental plan usually pays 50%-80% of the average total fee. The
amount paid is usually determined by how much you or your employer has paid for coverage or the type of
contract your employer has set up with the insurance company.
What does the term: "Usual, Customary and Reasonable fees" mean?
Often your dental insurer will reimburse you at a rate that is lower than the dentist's actual fee. This fee is
not based on what a dentist actually charges, but what each dental insurance company wishes to cover.
Frequently, insurance companies state that the reimbursement was reduced because "your dentist's fee
has exceeded the usual, customary, or reasonable fee (UCR)." 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 simply
is not accurate.
Each insurance company sets it's own payment schedule and "allowable fees." In most cases, the
allowable fees are set about 30% below actual industry standard and do not take into consideration the
fees charged by dental specialists (Pediatric Dentists, Orthodontists, Endodontists, etc.) These allowable
fees may vary widely between insurance companies and are determined so that the insurance companies
can make the profit they need in order to operate. In general, a less expensive insurance policy will use a
lower usual, customary, or reasonable (UCR) fee schedule. Dentists are not allowed to know what the UCR
or maximum allowable fees are for any procedure. In addition, insurance companies are not required to
disclose to the consumer, or the dental profession how they determine these fees.
Why didn't the insurance company cover my child's treatment?
One of the most frustrating issues to deal with is when an insurance company disregards standard
treatment that has been recommended by both the ADA and the American Academy of Pediatric Dentistry.
We occasionally see dental plans that do not cover standard, recommended procedures such as dental
sealants, topical fluoride application and even white "tooth colored" fillings. Since we do not have
information on the hundreds of dental plans available, the patients ends up being responsible for knowing
what exclusions and limitations are included in their plan.
Orthodontic Dental Insurance:
We will initially assist you with filing your claim for orthodontics to ensure that you receive your maximum
insurance benefit. A typical plan might cover 50 percent of the costs of braces up to $1,500-$2,500. Each
insurance company has it's own schedule for reimbursing subscribers for orthodontic treatment. Some
plans pay the subscriber periodically throughout the course of treatment, while others reimburse the
patient in full at the beginning of treatment. Most plans reimburse the patient monthly, based on the
monthly payment plan you have set up with our orthodontic office.
Because of the various types of reimbursement schedules, we require our patients to pay our office
directly for orthodontic services. Most patients select one of the convenient, monthly, no interest, payment
plans offered by our office.
PPOs and Private Insurance Networks:
We do not participate in, nor are we members of any organized dental insurance network, such as Delta
Dental. Many of our patients have this type of insurance and we assist them by filing their claims.
Generally, these programs will not reimburse our office directly, but rather, reimburse the patient. In these
cases, we ask that you pay for services the day of your appointment. Generally, most insurance carriers
process and pay claims to the subscriber within 2-3 weeks.
| 121 W. Woodcroft Parkway * Durham, NC 27713 * Fax (919) 489-2892 * Phone (919) 489-1543 |