Role of Insurance

Role of Insurance

Dental insurance is a contract between a third party (the insurance carrier) and your employer. It is intended to assist you in meeting the financial obligations related to your dental treatment. It is not intended to relieve patients of all financial responsibility.

It is the patient’s obligation to pay for the treatment rendered. Although we have no contractual relationship with any third party payer, we will assist you in completing claim forms so that your insurance carrier can reimburse you.

Medical and dental benefit plans differ markedly, particularly with regard to deductibles, coinsurance, yearly maximums, and scope of coverage. Virtually all dental policies have greater limitations on procedures covered, as well as benefits provided for those covered services. Benefits vary from group to group even if the same carrier or employer is involved. Contracts are based on premiums paid by the employer and may vary because of union/non-union or management/labor status. In addition, benefits are not based on the patient’s need for treatment, but on the limitations of their policy.

Most third parties will provide predetermination of benefits before treatment is initiated. A few plans even require it in order for benefits to be allowed. Your insurance carrier will inform you and your dentist of the extent of benefits for the proposed treatment, but will not guarantee payment of those benefits. There may be changes in employment status, contract terms, or payment for other dental services between the time the predetermination is issued and the actual claim with the date of service is reviewed and processed.

Patients must understand that most dental benefits contracts provide benefits for certain procedures (such as periodontal maintenance) only at a given frequency. If the patient’s periodontal condition requires that those services be provided more frequently than the stated limitation, they are the financial responsibility of the patient.

Payment may be denied for certain procedures even though the patient and the dentist agree that the submitted treatment plan is in the patient’s best interest. If the proposed treatment is provided, the patient must understand that payment is his/her sole responsibility.