Cosmetic Dentist - Tyler
4290 Kinsey Dr., Ste 3
Tyler, Texas 75703
(903) 561-0533
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Insurance Questions
What is an Annual Maximum?
Most dental programs have an annual dollar maximum. This is the maximum dollar amount a dental plan will pay toward the total cost of dental care within specific benefit period, usually the plan year. This "Annual Maximum" amount applies to cleanings, exams, and all dental treatment. The plan purchaser/employer makes the final decision on "maximum levels" of reimbursement the insurance company will be responsible for. The patient is usually responsible for paying costs above the annual maximum. Your employer may want to research plans that offer higher annual maximums when assessing how to better meet the needs of employees.
What are Treatment Exclusions?
A dental plan may not cover certain procedures or preventive treatments. This does not mean that these treatments are unnecessary. Patients need to be aware of the exclusions and limitations in their dental plan but should not let those factors determine their treatment decisions. Another common exclusion is a night guard, some insurance plans do not cover this treatment even though it is critical for the protection of patients who grind or clench their teeth. Your dentist can help you decide what type of treatment is best for you.
What are Plan Frequency Limitations?
There are some procedures that may not be covered as often as necessary for optimal health. A common limitation is for a dental plan to only pay for a cleaning twice a year even though the patient requires a cleaning every 3 months. The limitations will vary depending on the dental plan that was purchased.
What is UCR (Usual, Customary and Reasonable)?
Usual, customary and reasonable charges (UCR) are the maximum amount that will be covered by the plan for eligible services. If the dentist is a Preferred Provider for the insurance company, than the plan pays an established percentage of the dentist's fees. If you see a dentist that is out of network, or you have a plan that allows you to see any dentist of your choice, then the insurance will pay the plans "customary" fee or "reasonable" fee limit, whichever is cheaper. Although these fees are called "customary", they may or may not reflect the fees that area dentists charge. If the fee exceeds the plan's "customary" fee, it does not mean your dentist has overcharged for the procedure. Why? There are no regulations as to how insurance companies determine reimbursement levels, resulting in a wide fluctuation. Insurance companies are also not required to disclose how they determine "usual, customary and reasonable" charges.