We accept all major DPPO plans. We are In-Network with:
- Lincoln Financial
- United Concordia
- United Healthcare
Most patients have questions about what their insurance covers. There are a few factors that play into your insurance and it’s coverage. Let’s define some important terms:
- In-Network– A contractual relationship DOES exist between the dental provider and your insurance company by which your insurance company sets the fees for all procedures performed.
- Out-of-Network– A contractual relationship DOES NOT exist between the dental provider and your insurance company. Fees are usually based off of the UCR fees of that specific office. Your insurance company will still pay for treatment performed by an out-of-network provider. Larger procedures will be covered at a lower percentage.
- UCR Fees– Usual, customary and reasonable fees that a dental practice charges for any given procedure. These are the prices used for patients that don’t have dental insurance or going to a dentist that is out-of-network.
- Premium– A monthly bill that you pay the insurance company to maintain dental insurance coverage.
- Waiting Period– A time period in which you’ve paid the insurance premium and have obtained coverage but the insurance company will not pay for any dental work performed. This is how insurance companies make sure that you don’t get dental insurance for a month, do a large procedure and then drop them.
- Deductible- The amount of money that your insurance carrier requires you to pay before your coverage kicks in and will pay a percentage. This is similar to what medical insurance companies do.
- Annual Maximum- A set maximum amount of money that your insurance company will pay towards your dental treatment in a given year. Maximums can range from $200 per year to unlimited (this is rare).
- Co-Pay or Co-Insurance- A portion of the dental treatment cost that is not covered by your dental insurance that is due at the time of treatment. This amount is determined by your insurance and the type of work being done.
- Predetermination– A process where we submit all applicable proofs and records necessary for the insurance company to determine how much of the procedure will be covered before treatment is started. These are great for large procedures so you are prepared for what will be covered by your dental insurance company. Insurance companies typically follow what they say they will pay on these documents. The whole process of submitting and receiving the predetermination may take up to 4 weeks depending on the time of year and the insurance company.
- Reimbursement Levels– This is tricky to explain. Treatments fall under 3 main categories. These include:
- Diagnostic/Preventive- Includes routine cleanings, x-rays, and check-ups by the dentist. Insurance companies usually cover these treatments at 100%.
- Minor– Includes deep cleanings, fillings, etc. Coverage in the minor group is dependent on your insurance carrier and the specific coverage plan.
- Major– Includes crowns, root canals, dentures, etc. Coverage in the major group is dependent on your insurance carrier and the specific coverage plan.
The following are types of dental insurance:
- DPPO- Accepted by most dental providers and is the most flexible type of dental insurance. DPPOs give you the control in choosing your dental provider; however, the premiums are the highest.
- DHMO- Accepted by very few dental providers in relation to DPPO plans and are very restrictive in which dental providers you see. The insurance company pays the dentist an “allowance” every month for having you on their books. Dentists that are on these plans are usually required to see a specific number of patients per month so they tend to be rushed and don’t have as much time to spend with their patients.
- Medicare/AHCCS- By and large Medicare doesn’t cover dental, but there are exceptions. AHCCS is accepted by very specific dental providers and AHCCS won’t pay unless you visit a provider on their list. AHCCS tends to cover procedures on children pretty well but usually only covers extractions for adults. Approval is usually required from AHCCS before treatment can be performed, which delays necessary treatment and may cause frustration.
If you have two dental insurance companies, estimates of what your insurance companies pay are nearly impossible to predict. The insurance companies communicate and each determines what they will pay. The bright side is that you have better coverage and the companies pay more than if you only have one dental insurance.
As you can see from above, dental insurance terminology is its own language and can be very tricky to navigate. The best way to navigate your insurance is to have a dental office request a benefit summary from your insurance company and then review it with you. As with all insurance companies, it can be difficult to predict what exclusions or fine print the insurance company may use to not pay for service. At Sonoran Frost Dentistry, we bill your insurance as a courtesy to you. We are a third party between you and your insurance company. We help you settle disputes with them, but there are times when you, the insured, will need to call the insurance company yourself to get things done.