• Usual Customary Rate (UCR)
Insurance companies can set whatever amount they want and they are not required to show how they got their fee schedules.
If your dental bill is higher than what the insurance co will pay for, it doesn’t mean that your dentist is charging too much. It could mean that they have not updated their UCR charges, or they were set for a different area than where you live
• Annual Maximums
This is the total amount of dollars your insurance will pay on your behalf.
Your employer decides what the annual maximum is, if it is too low to meet your needs, you can ask your employer to look into other plans.
• Preferred Providers
You may have to choose from a network of preferred providers.
If you get dental care from a dentist who is out of network, your out-of-pocket costs may be higher.
• Pre-existing conditions
Your plan may not cover conditions that existed before you enrolled in the plan.
Even though your plan may not cover certain conditions, you may still need treatment to keep your mouth healthy.
• Coordination of benefits (COB)
This applies to patients that are covered by more than one plan.
Each insurance company handles COB in its own way, and doesn’t guarantee that all charges will be covered.
• Plan frequency limitations
This is how many times per year or lifetime your insurance company will pay for certain treatments.
For example: Your plan may cover 2 teeth cleanings per year, but you need more to maintain a healthy mouth. Be sure to make treatment decisions on what is best for your health, not just what is covered by your plan.
• Not Dentally necessary
Most insurance companies will only pay for treatments that are dentally necessary, but you and your dentist can make the decisions that are best for you.
If your insurance company denies a treatment, you can appeal. You can work with your dentist’s office and the plan’s customer service department to appeal the decision in writing.
• Other Cost control measures
Bundling: This is when the insurance company combines two services into one; this may reduce your benefit.
Down coding: This is when the insurance company changes the procedure code to a less complex or lower cost procedure than was reported by your dental office.
• Least Expensive alternative(LEAT)
Your plan may have an LEAT clause. This means when there is more than one way to treat a condition; your insurance company may only pay for the least expensive treatment.
For example: Your dentist may recommend an implant for you, but the plan may only cover less costly dentures.
In any case, it is always a good idea to look through your plans benefit schedule, and talk to your dentist office about the best plan to choose.
Source: The American Dental Association