Many of the patients we see here at Phoenix Endodontic Group have some form of dental insurance coverage. These benefits can make affording needed treatment much more feasible for many of our patients. However, as a patient with insurance, it is important to understand that simply having coverage does not guarantee the specific services you need will be paid for or covered by your dental plan. Here at Phoenix Endodontic group, we cater to our patient’s specific oral health needs. We feel it is important our patients understand their individual needs sometimes do not fit within the constraints of plan used to cover an entire group.
Two of the most common misassumptions by patients regarding their dental insurance are first, that their dental insurance covers all dental procedures (codes) and secondly, their dental plan will cover the entire cost of a specific procedure or treatment. Most dental plans are contracted between a patient employer and an insurance company. This means the employer and the chosen insurance company agree upon what procedures will be covered and how much the plan will pay for these procedures. If you have questions about your plan or coverage, please contact your insurance company or employer.
It is possible that your dentist may recommend treatment that is not covered by your dental plan. Here at Phoenix Endodontic Group, we are healthcare providers first, and our patient’s oral health is our number one concern. Decisions made regarding treatment should be done with the advisement of your dentist, and not dictated by insurance.
Below are some key terms used when discussing dental insurance. Being familiar with these terms can help you better understand your coverage.
Plan Frequency Limitations
A dental plan may limit the amount of times it will pay for or cover a specific service. However, some patients may need a service more often than others to maintain oral health. For example a plan may only pay for two exams per year. A patient may have already used those exams with their general dentist and may not have coverage for a third exam when they see a specialist (for example an Endodontist). Patients should make treatment decisions based on what is best for their health, and not allow treatment decisions be dictated by their insurance.
Coordination of Benefits (COB) or Non Duplication of Benefits
These terms are applicable to patients with dual coverage, or are covered by more than one dental plan. The sum of benefits paid from all insurance plans should not be more than the total charges for service rendered. Although a patient is covered by two or plans, this does not guarantee that all the plans will pay for services rendered. Sometimes, none of the plans will pay for treatment needed. Each insurance company handles COB in a specific way and it is important you check with your plan for details.
Not Dentally Necessary
Most dental insurance plans sat they will only cover procedures considered to be medically or dentally necessary. However if the claim is denied for this reason it does not mean the services were not necessary. If you plan rejects a claim because a service was not deemed not “dentally necessary” you can file an appeal. Remember treatment decisions should be made by yourself and your dentist.