Why Dental Insurance Really Means Dental Benefit

by Sam Morgan, Practice Administrator

If you don’t work in healthcare — or even if you do — you may not understand your dental insurance. I know I didn’t understand any of my benefits when I worked in the corporate world.

It is very commonplace and normal to think that if you have dental insurance, you should be covered for your normal hygiene maintenance procedures and any needed surgeries. Unfortunately, this is not the case. So, let’s take a few minutes to review some dental insurance basics:

  1. Dental insurance is really a dental benefit that is allotted to you each year. These benefits usually run on a calendar year but sometimes run on different 12 month cycle.
  2. We call dental insurance a dental benefit because, unlike most health plans, there is a defined or limited amount of benefit available to you each year.
  3. Coverage for dental benefits under companies, plans, and groups will vary. Dental benefits are most commonly covered at a percentage of the fee charged by your dental professional. For instance, Sally may have 80% coverage with Company A for a cleaning while Bill has 60% coverage for the same cleaning under Company B.
  4. Routine cleanings, exams, and x-rays are all covered at different levels within dental insurance companies. You should be aware of frequency limitations in the number of times per year (or any defined time period) that these services can be performed.
  5. To find out exactly what may — or may not — be covered and at what percentage it is covered, you may want to request that your dental professional file a Pre-Authorization or Pre-Determination prior to a procedure. This is a recommendation based on procedure code and your dental insurance company requirements.
  6. You should receive an Explanation of Benefits (EOB) each time your dental Insurance is billed for a procedure. If you don’t receive this information, you should contact your dental insurance company for a copy. If you have any trouble understanding your EOB, I recommend that you contact your dental professional for help understanding the document.
  7. Common language you may hear in a dental office, on the phone with your dental insurance company, or see on a Explanation of Benefits includes
  • Dentist = Provider
  • Insurance Company = Carrier
  • ADA Code = Dental Code, a four digit number that follows a D (e.g., D0120)
  • EOB = Explanation of Benefits
  • Maxed Out = patient has utilized all of their benefits for the year
  • Frequency = number of times a procedure may be performed within a defined time period

The bottom line is that insurance is constantly changing, and it can be very complicated to understand. However, it is important to understand your benefits. Ask questions of your carrier and your provider. Don’t be embarrassed if you don’t understand or even if you need it explained more than once.

Each year, you may go through Open Enrollment at work. Take that opportunity to speak with your HR department and your dental professional about the options available to you.

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