Insurance FAQs

One of the first questions we receive from potential new patients is whether or not we are in their insurance network. The answer to this question can be confusing…

We are able to accept most dental insurance plans as long as they are PPO Plans (Preferred Provider Option, this means you have Out-of-Network benefits and do not have to pick off of a list of providers). Unfortunately, we cannot accept HMO, DMO, discount plans, or Medicare plans, but we would still be delighted to see you in our office.

PPO is short for preferred provider option. This means you can choose to see any dental professional that you desire. Other plans limit who you have the ability to see for your dental care, which hinders us from accepting them.

We are always happy to do a complimentary insurance benefits check for you prior to your appointment.

Medical and dental insurance are different. They may be handled by the same insurance company, but they are two completely different policies. The best way to be sure is to contact your human resources department to clarify who your dental insurance provider is.

To verify your benefits we need the name and phone number of your insurance company. We also need the name of the employer or group the insurance is provided under, the legal name of the policy holder and their social security number, date of birth, and member identification number. We also need the patient’s legal name and date of birth. For your personal security, we cannot check on your benefits without this information and this information is securely shredded following the benefits check *Please note that if you have MetLife dental insurance, we will also need the zip code that they have on file for you to check on your benefits.

In most cases with dental insurance, in network and out of network benefits are typically very similar, especially for preventative and diagnostic services. 

Out of Network does NOT mean that your dental services are not covered by insurance. It also does not (necessarily) mean that your insurance won’t cover the procedure. In fact, most of the time – although this can vary depending on the details of your specific insurance plan – the procedures will cost you the same out of pocket, with the same percentage covered.

The only thing that “out of network” means is that the billing system is different, there is a little more verification that has to happen, and the order of how the procedure is paid for and billed is a little different. We’re happy to explain this to you more on a call, but the essence of this is: you are likely to pay about the same – if not completely the same – and have the same coverage with an out of network provider compared to in-network.

As our patient, you should be reimbursed for some or all of the procedures, just like you would if we were in network. But you’re also getting some of the benefits that come from choosing an out of network provider:

• Great dentist.
• No cutting corners.
• More time with the dentist and staff.
• Better materials, technology, and more.

The insurance company only provides us with an estimate of coverage. They can change fees and processing guidelines at any time and have different rules that affect what services they cover based on each individual patient. We are happy to submit a Predetermination for Services that are not preventative and diagnostic to give you a more accurate estimate of your benefits. We are unfortunately unable to guarantee any payment on services due to the insurance companies’ rules and regulations.

When you are looking for dental insurance, it is best to speak directly with someone at the insurance company. Online searches are limited in some of the information they provide and you want to ensure that you get the best benefits for your dental needs.

Important questions to ask insurance companies.

• Is the plan on a fee schedule? If the plan is a fee schedule, this means the insurance company will almost always pay less for services, even if you are seeing an In-Network provider. For example, they may pay 100% of $5 for a cleaning that costs $90 and you are stuck paying the remaining $85.
• Does the plan have a waiting period? If the plan has a waiting period, this means that you have to wait to get certain services performed. For example, they may have a 12 month waiting period for a crown which means that you have to wait one year from the day you signed up for the policy before the insurance company will help pay for it. So, if you want the crown sooner, you would have to pay the full amount for your crown.
• Is there a missing tooth clause? If the plan has a missing tooth clause, this means that the plan will not pay to replace missing teeth. For example, if you wanted an implant or bridge to replace a missing tooth, the insurance company would not pay to replace it if it was extracted prior to the start date of the coverage. The full cost for the implant or bridge would be your responsibility.
• Does the plan only cover preventive and diagnostic services? If the plan only covers preventive and diagnostic services, this means that they will only have coverage for your exam, basic cleanings, and x-rays. These plans tend not to have coverage for fillings and will not have coverage for periodontal cleanings, root canals, crowns, bridges, and implants. For example, if you needed a filling, the insurance company would not cover it so you would have to pay the full amount out of pocket.