Insurance network change faqs

Q) What questions should I ask my insurance about my OON coverage?

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Our team verifies that your plan is active and collects basic benefit information from the insurance company in order to submit claims and calculate estimated copays but it is ultimately the patient’s responsibility to understand the benefit and network restrictions of their specific dental insurance plan. We highly advise our patients to familiarize themselves with the details of their dental insurance plan. Below are some of the questions we feel are important for patients to ask their insurance company:

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Questions to ask (basics - more information about these in section below):

• What are my out of network benefits?

• What’s Annual Max & Deductible - and what types of services does my deductible apply to

• What are the coverage percentages for: preventive, basic, major, implant

• How frequently will my plan cover: cleanings, exams, xrays?

• What is my “plan year” (when does my plan reset each year)?

• Is there a “waiting period”?

• Is there a “missing tooth clause”?

• Are there any material downgrades?

• Is assignment of benefit to the provider accepted for out of network providers?

• “What is the maximum allowable charge for X, Y & Z codes if I were to see an out-of-network provider?

• Ask for specific fees below. If they won’t give you that, ask if our fees are within or above their MAC/UCR.

• Check Codes/Fees:

  • D1110 - Prophylaxis (dental cleaning)  - $138

  • D0120 - Periodic Exam - $70

  • D0210 - Full Series X-ray - $185

  • D0274 - Four Bitewing X-rays - $86

  • D2391 - 1-Surface Filling - $266

  • D2740 - Porcelain Crown - $1565

  • D2950 - Build-up (often required with a crown) - $325

  • D7210 - Surgical Extraction -  $390

• Please Note: Your annual maximum applies to ALL services. If you reach your annual maximum benefit, your insurance will not pay for ANY other services (including cleanings & exams) until your plan year resets. 

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Questions to ask (same questions, just with a little more explanation)

• What are my out of network benefits? - Are there out of network (OON) benefits? If there are NO out of network benefits (ONN), you'd need to see an in-network provider for the insurance to contribute towards the cost of treatment. MOST dental plans include at least some out of network benefits, many offer OON benefits that are quite comparable to the in-network benefits. Having OON benefits allows patients the freedom to choose their provider based on their own preference. 

• What is my annual maximum benefit? What is my annual deductible and does it apply to preventive services? The standard annual maximum is ~$1500. This means that you insurance will not pay more than $1500 towards your dental claims in any given plan year. The most common deductible is $50-$100 and does not apply to preventive services. If your plan’s deductible does apply to preventive services, then you would need to pay that deductible at your first visit of the plan year, even if it’s just a cleaning visit. 

• What is my “Plan Year”? Most plans run on a calendar year, which means the annual maximum and deductible reset every January. However, the plan year can vary from plan to plan. It’s important to know when your plans benefits reset each year. 

• Coverage percentages for:

  • ​Preventive/diagnostic

  • Basic

  • Major

  • Implant

  • Ortho 

• Standard coverage is: 100% preventive, 80% basic, 50% major and if there is implant and/or ortho coverage, those are usually 50% too. 

• Typically,” preventive/diagnostic” services are things like cleanings, exams and most xrays. Fillings are typically considered “basic” services. Things like crowns & bridges are often considered “major” services. 

• How frequently will my plan cover: cleanings, exams, xrays?Ask about frequency limitations for the following code:

  • D1110 - Prophylaxis (standard dental cleaning)

  • D0120 - Periodic exam (there are several types of exams and typically, they all share frequency. 

  • D0274 - 4 Bitewing Images (there are the xrays we take annually)

  • D0210 - Full Mouth Series Xrays (we recommend a full series xrays be taken every 3-5 years)

• Is “assignment of benefit” to the provider accepted for out of network providers? They will likely say either, “as long as there is a signature on file” or “no”. As long as assignment of benefit is accepted, the option for payment to be sent to the provider exists. If it’s not accepted, insurance payment will only go to the patient, so we (the provider) will have to collect in full, up front, for treatment and the patient would be reimbursed by insurance. 

• Is there a “waiting period”? If there is a waiting period, how long is it? And what types of services does it apply to? If there is a waiting period, your insurance won’t contribute towards that type of service until the waiting period has been met (and until you’ve paid for the plan for that long). Most frequently, we see waiting periods that last 6-12 months and do not apply to preventive services like cleanings and exams. 

• Is there a “missing tooth clause”? If there is a “missing tooth clause”, the insurance won’t pay for the restoration of a tooth that was extracted prior to the start of the plan’s coverage. So if you had a tooth extracted prior to the start of your insurance coverage, the new plan won’t contribute towards the cost of a bridge or implant to replace that extracted tooth. 

• Are there any material downgrades? Some insurance plans still include a clause so that they can elect to only pay towards the cost of amalgam (silver) fillings or metal crowns on posterior teeth (those teeth that typically don’t show in your smile). These plans consider composite (white) fillings and porcelain crowns an “elective upgrade”, despite the fact that these have been the standard of care for all teeth for decades (there are still some specific instances in which amalgam fillings or metal crowns are the more ideal treatment, but it’s not very often). The insurance will pay the covered percentage of the lower fee and the patient is responsible for the difference.

• “What is the maximum allowable charge for X, Y & Z codes if I were to see an out-of-network provider?” - Just because a plan says it covers 100%, does not mean it covers 100% of the fee we (or any other office may) charge. When patients see an in-network provider, that provider has agreed to a set “fee schedule”. These are fees set by the insurance company and the in-network provider is contractually obligated to charge for covered services. Maximum Allowable Charges (MAC) or Usual & Customary Rates (UCR) are the usual terms for the dollar amounts that insurance companies use to process claims for out of network providers. Most UCR rates are well above our office fees, so 100% coverage actually means 100% coverage. But occasionally, the MAC/UCR is lower than our office fee, which would mean insurance will pay 100% of that lower fee and leave the patient  responsible for anything above it.  See example below:​​