Insurance Benefit Information
Your endodontist wants you to understand how dental insurance works and how to make it work best for you. You should also understand how the treatment your endodontist provided works with your dental plan.
The contract your employer negotiated with your insurance carrier defines your dental benefits. Please read the benefit or insurance plan booklet provided by your employer so that you better understand your benefits. Various dental plans cover endodontic procedures at different payment levels and, as a result, your payment portion may vary.
This section answers frequently asked questions about dental benefits. If you do not find the answers to your questions, contact your plan or benefits administrator who can explain the details. If you see an insurance term with which you are not familiar, please see the glossary of terms.
“UCR” is the term used by insurance companies to describe the amount they are willing to pay for a particular endodontic procedure. There is no standard fee or accepted method of determining the UCR, and the UCR has no relationship to the fee charged by your endodontist. The administrator of each dental benefit plan determines the fees that the plan will pay, often based on many factors including region of the country, number of procedures performed and cost of living.
Your dental benefit may vary for a number of reasons, such as:
• You have already used some or all of the benefits available from your dental insurance.
• Your insurance plan paid only a percentage of the fee charged by your endodontist.
• The treatment you needed was not a covered benefit.
• You have not yet met your deductible.
• You have not reached the end of your plan’s waiting period and are currently ineligible for coverage.
Your endodontist diagnoses and provides treatment based on his or her professional judgment and not on the cost of that care. Some employers or insurance plans exclude coverage for necessary treatment as a way to reduce their costs. Your plan may not include this particular treatment or procedure, although your endodontist deemed the treatment necessary.
Your payment portion will vary according to the UCR of your plan, your maximum allowable benefit and other factors. Ultimately, the patient portion is not known until the insurance check has been received by you endodontist.
Your Explanation of Benefits (EOB) contains a wealth of information. The EOB identifies the benefits, the amount your insurance carrier is willing to pay and charges that are and are not covered by your plan. The statement includes the following information: UCR, co-payment amount/patient portion, remaining benefits, deductible and benefit paid.
The time for a dental insurance carrier to process an insurance claim varies. At least 38 states have enacted laws requiring dental insurance carriers to pay claims within a timely period (ranging generally from 15-60 days). If you want to file a complaint about a delayed payment, contact the insurance commissioner in your state. He or she wants to know if your insurance complaint does not pay within the period allowed by your state law. A link to the names and addresses of commissioners is posted on the American Association of Endodontists’ web site, www.aae.org.
Most endodontists fall in one or more categories, and there may be more options than are described here. Some endodontists sign contracts with dental insurance carriers and agree to accept or “take” the payment offered by the insurance company as payment in full, even though it may not be the same amount as the endodontist charges for the procedure. These endodontists are Participating Providers in your plan.
Other endodontists do not sign contracts with dental insurance carriers, but still accept or “take” insurance company payments. These endodontists are not contractually obligated to accept your insurance carrier’s payment as full compensation and are not Participating Providers. In this instance, you may be responsible for a payment portion over and above the percentage provided by your insurance company.
Still other endodontists are not Participating Providers and do not accept payments directly from your insurance carrier. In this case, your endodontist will ask that you be responsible for the entire fee, but will assist you in filing your claim to receive insurance benefits directly from your insurance carrier.
Your endodontist will do his or her best to answer all of your insurance questions. Please keep in mind that there are many insurance plans available and that your employer chooses your plan and your benefits. If you believe your benefits are inadequate, you may want to discuss the matter with plan administrator and explore appropriate alternatives.
Glossary of terms
Assignment of benefits – Authorization from the patient to the insurance carrier to forward payment directly to the endodontist for covered procedures.
Claim – Statement sent to an insurance carrier that lists the treatment performed, the date of that treatment and an itemization of associated costs. It serves as the basis for payment of benefits.
Contract – An agreement between your employer and your insurance carrier that typically describes the benefits of your dental plan.
Copayment – The part of the fee you owe the endodontist after your insurance carrier has paid its portion
Coverage – The benefits available to you under your plan.
Customary fee – The fees your insurance carrier will pay for the specific procedure performed as opposed to the actual fees submitted for a specific endodontist procedure to establish the maximum benefit payable for that specific procedure.
Deductible – The amount you are responsible to pay before the insurance carrier will allow your benefit plan to pay the endodontist.
EOB – Identifies the benefits (the amount your insurance carrier is willing to pay) and charges covered by your plan.
Participating provider – An endodontist who signs a contractual agreement with the dental insurance carrier to provide care to eligible members.
Patient portion – The dollar amount that you will be responsible for paying if your insurance payment does not cover the entire fee.
Preauthorization – A statement from your insurance company indicating whether the required endodontic treatment will be covered under the terms of your plan.
Predetermination – An administrative procedure that required your endodontist to submit a treatment plan to your insurance carrier for approval before treatment begins.
UCR – A term used by insurance companies to describe the amount they are willing to pay for a particular endodontic procedure.