Some plans encourage you or your dentist to submit a treatment proposal to the plan administrator before receiving treatment. After review, the plan administrator might determine the patient’s eligibility, the eligibility period, services covered, the patient’s required co-payment, and the maximum limitation. Some plans require pre-determination for treatment exceeding a specified dollar amount. This process is also known as pre-authorization, pre-certification, pre-treatment review or prior authorization.
Annual benefits limitations
To help contain costs, your plan might limit your benefits by number of procedures and/or dollar amount in a given year. In most cases, particularly if you’ve been getting regular preventive care, these limitations allow for adequate coverage. By knowing in advance what and how much your plan allows, you and your dentist can plan treatment that will minimize your out-of-pocket expenses while maximizing compensation offered by your benefits plan.
Peer review for dispute resolution
Many plans provide a peer review mechanism through which disputes between third parties, patients, and dentists can be resolved, eliminating many costly court cases. Peer review is established to ensure fairness, individual case consideration, and a thorough examination of records, treatment procedures, and results. Most disputes can be resolved satisfactorily for all parties Ultrasonic Scaler.
Premium adjustments and re-evaluations. Patients and plan purchasers should insist on regular reviews of premium levels to ensure that UCR or Table of Allowances payment schedules are equitable. This analysis can help optimize your benefit levels, ensuring that every dollar you spend is used wisely.
Coordination of benefits. If you are covered under two dental benefits plans, notify the administrator or carrier of your primary plan about your dual coverage status. Plan benefits coordination can help protect your rights and maximize your entitled benefits. In some cases, you might be assured full coverage where plan benefits overlap, and receive a benefit from one plan where the other plan lists an exclusion dental equipment.
What key features of a dental health plan should I look for when selecting among dental plan options?
In reviewing and comparing health plans, consider the following when determining whether the coverage will satisfy your dental care needs:
Does the plan give you the freedom to choose your own dentist or are you restricted to a panel of dentists selected by the insurance company? If restricted to a panel, is your dentist on this panel?
Who controls treatment decisions – you and your dentist or the dental plan? Some plans might require dentists to follow the “least expensive alternative treatment approach.”
Does the plan cover diagnostic, preventive, and emergency services dental instruments? If so, to what extent?
What routine treatment is covered by the dental plan? What share of the cost will be yours?
What major dental care is covered by the plan? What percentage of these costs will you be required to pay?
What are the plan’s limitations (a limit to the benefits for a procedure or the number of times a procedure will be covered) and exclusions (denied coverage for certain procedures)?
Will the plan allow referrals to dental specialists? Will my dentist and I be able to choose the specialist?
Can you see the dentist when you need to and schedule appointment times convenient for you?
Who is eligible for coverage under the plan and when does coverage go into effect?
Your dentist cannot answer specific questions about your dental benefit or predict what your level of coverage for a particular procedure will be. Each plan and its coverage varies according to the contracts negotiated. If you have questions about coverage, contact your employer’s benefits department, your dental health plan, or the third-party payer of your health plan.How Long Will It Take? for more information.