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Many patients have questions regarding dental benefits. Figuring out your dental benefits is not easy, and we try to help you understand your plan. Whether your plan covers a minor or major portion of your dental bill, all dental benefits help patients pay for needed treatment. Although your Employee Benefits Coordinator at work may answer your questions best, we have answered many common questions. Why doesn't my insurance cover all the costs for my dental treatment? Dental insurance isn't really insurance (a payment to cover the cost of a loss) at all. It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment. The employer usually buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost. But my plan says that my exams and certain other procedures are covered 100%25? That 100%25 is usually what the insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge. For example, say your dentist charges %2480 for an examination (not counting x-rays). Your carrier may allow %2460 as the 100%25 payment for that examination, leaving %2420 for you to pay. If my plan does not really cover any procedures at 100%25, why does it say it will? Benefit plan booklets are often difficult to understand. If any part of your plan is not clear to you or if you think something is wrong concerning what your plan covers, you should contact your Employee Benefits Coordinator or the Human Resource department where you work. How does my insurance carrier come up with its allowed payments? Many carriers refer to their allowed payments as UCR, which stands for usual, customary, and reasonable. However, usual, customary, and reasonable does not really mean exactly what it seems to mean. UCR is actually a listing of payments for all covered procedures negotiated by your employer and the insurance company. This listing is related to the cost of the premiums and where you are located in your city and state. Your employer has likely selected an allowed payment or UCR payment that corresponds to the premium cost they desire. UCR payments could be more accurately called negotiated payments. Since the payments are negotiated, does this mean that there is always a balance left for me to pay? Typically there is always a portion that is not covered by your benefit plan. If I always have a balance to pay, what good is my insurance? Even a benefit plan that does not cover a large portion of the cost of needed dentistry pays something. Any amount covered reduces what you have to pay out of pocket. I received an Explanation of Benefits from my insurance carrier that says my dental bill exceeded the usual and customary. Does this mean that my dentist is charging more than he/she should? Remember that what insurance carriers call usual and customary is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment. It is usually less and frequently much less than what any dentist in your area might actually charge for a dental procedure. It does not mean that your dentist is charging too much. Why is there an annual maximum on my benefits? Maximums limit what a carrier has to cover each year. Amazingly, despite the fact that costs have steadily increased, annual maximum levels for dental care have not changed since the 1960's. Why do some benefit plans require me to select a dentist from a list? Usually the dentists on the list have agreed to a contract with the benefit plan. These contracts have restrictions and requirements. If you choose a dentist on the list, you typically will pay less toward your dental care than if you choose a dentist not on the list. If your dentist is not on the list this does not mean that something is wrong with the dentist or the office. Why does my benefit plan only pay toward the least expensive alternative treatment? To save money, many dental plans allow a benefit only for the least expensive method of treatment. For example, your dentist may recommend a crown, with your insurance only offering a benefit towards a filling. This does not mean that you have to accept the filling. The good news is that some benefits will be paid; the bad news is that more of the fee will be your responsibility. Remember that your dentist's responsibility is to prescribe what is best for you. The insurance carrier's responsibility is to control payments. Why won't my insurance pay anything toward some procedures, such as x-rays, cleanings, and gum treatments? Your plan contract specifies how many of certain types of procedures it will consider annually. It limits the number of x-rays, cleanings, and gum treatments it will cover because there are the types of treatments that many people need to have frequently. I know that my insurance plan doesn't go into effect until next month. Why won't my dentist do my treatment today, but send in the claim next month so that the insurance will pay? State laws regulate these issues. It is insurance fraud to change the dates of service on a claim. Both the patient and the dentist can be prosecuted.