Dental Insurance San Mateo

Assignment of Dental Benefits:

Most insurance plans allow for you to assign benefits to our office. However, in Pennsylvania there are two carriers, United Concordia and Delta Dental, PA which typically do not allow you to assign your dental benefits here. This means these two dental insurance companies will not send your dental benefit check to our office but will only send your dental benefits payments directly to the plan subscriber. These two carriers will only send dental insurance payments to a dentist if that dentist is participating within their network of dental care providers. For many reasons including my fundamental desire to allow patients the right to choose their care provider and to not have your treatment choices influenced by a for profit insurance carrier, I do not participate with any dental insurance carrier network. The good news is there is active, pending legislation that would outlaw this practice and provide patients the right to choose their provider without interference by insurance carriers. The majority of US states have already adopted such laws and hopefully PA will soon join the majority and support patients’ rights.

Pre-Determinations (Pre-D) of Dental Insurance benefits:

In order to better predict dental coverage levels, our office can submit a pre-determination to your carrier. It typically takes about 3 weeks to get back and it will tell us if the planned care is covered and if so, to what extent. All pre-D’s carry the disclaimer that this is not a guarantee of benefits as the annual maximum may have been reached, the plan may have been terminated prior to the care being done or some other change may have occurred that would cause your policy to now no longer allow for payment. Typically, pre-determinations are quite accurate and provide a better understanding of your expected dental benefit allowances prior to treatment.

Missing tooth clause:

When planning to replace a missing tooth, sometimes a dental policy has a missing tooth clause. Essentially, this states that any tooth missing prior to the effective date of coverage will not be entitled to any benefit reimbursement for the cost to replace the missing tooth.

Primary and Secondary Dental Insurance: If you have coverage under two dental insurance policies, one policy will be your primary insurance and the other will be your secondary. We must submit to your primary insurance first prior to submitting to your secondary, even if we know the primary will provide little to no benefits. Your secondary carrier will typically require a copy of the primary insurance EOB (explanation of benefits) in order to determine your benefits payable under your secondary policy. We appreciate this can be frustrating but it is something we are unable to alter. We must follow the required format or your claim will be rejected.

Birthday Rule for Dental Insurance:

If you have two dental policies, insurance companies direct which one will be your primary. Currently, it is not an option to choose which plan will be considered your primary coverage. The primary is determined by the earliest birthday of the policy holder.

Non-Duplication Clauses:

The standard definition of “non-duplication clause” is this: If a patient is covered under two plans and primary pays 80% of the claim, the secondary will not duplicate the benefit. So, if the secondary benefit is also 80%, the secondary plan will pay nothing or only 80% of the remaining 20% (after the secondary deductible is met)..

Non-covered dental care services:

Too often a patient will have a clear care need and will have an active insurance policy but still receive no dental insurance dollar benefit. This is usually due to a specific exclusion in their dental policy which does not provide coverage for a type of treatment. No matter how clear the need, there will be no insurance reimbursement benefit for that care. Implant care is often not covered but is slowly being covered by more carriers. Typically, cosmetic care is not covered.

Minimal alternative treatment:

When a space is present from a missing tooth, there are different options available to replace that tooth. Typically they are a partial denture, a bridge or an implant. Some plans will only pay their percentage based upon the cheapest alternative, the partial denture, regardless of the actual choice of care made by you.

Appeal of a claim denial:

If a claim is denied, it may be appealed. Only the patient can file an appeal. We can assist by writing a narrative, submitting copies of radiographs and clarify any coding as needed but the appeal process is not open to the provider, only the patient.