Coverage can be a tricky thing in the dental insurance world.  There are rules to follow and if you make an error in some of your calculations, it’s gonna cost YOU, not them.

Have you ever called your insurance carrier and got the automated system (which I personally hate!) heard these words:

“Please be aware the benefits quoted are not a guarantee of payment.”  Well that disclaimer is just what is say it is, IT IS NOT A GUARANTEE OF PAYMENT!, especially if you don’t follow the rules!

Let me go over some of the detailed information you need to look for when flipping thru all of the pages and attempting to read all of that fine print in your dental insurance policy.

Effective date:

Be sure to check when your insurance became effective and don’t forget to find out if some procedures have a waiting period.  Waiting periods usually apply to orthodontic coverage but can be applied to other procedures depending on the policy.

Coverage & Frequency:

Preventive dental procedures (dental cleanings and examinations) coverage with most insurance is covered at 100% of U & C, however, the insurance plan may only cover these procedures 2 times within a calendar year and the coverage may only be liable if you have these procedures done every 6 months.  If you go into the office have this work done before the 6 month time frame, your insurance will not pay, no matter how much you complain or try to explain what had happened.  I suggest your appointments should always be 6 months and 1 day after your last visit, this way your insurance carrier can’t say “Procedure(s) not covered due to Frequency limitation”.

X-rays are usually covered somewhere between every 36 to 60 months, yes every 3 to 5 years.  Be sure to check your policy on this one.  However, you must remember sometimes your dentist may require to take an x-ray or two before this frequency is due, especially if tooth decay is suspected.  You may just have to bite the bullet on this one and have it done and pay for it yourself.

Other procedures such as root canals, crowns may vary from one year to one in every 5 years, so please, please, please read your policy and if you are not sure of the coverage due to the occasional cryptic language, CALL THEM and speak with someone with a pulse!

Don’t forget, deductibles may or may not apply according to the procedure(s), please check this information also.

Age Limitations:

Age limitations usually apply to procedures such as fluoride treatments, sealants, and let’s not forget, orthodontics (I’ll update you on that on in the next entry).

Most insurance carriers will cover children up to the age of 19 and possibly for some procedures up to 23 or 26 if and only if they are able to provide proof of being an active student (see the paragraph on Dependents)

Not only do sealants have the age limitation rule attached to them but there may also be a limit on which teeth are covered.  Most insurance carrier only cover sealants on the 1st and 2nd bicuspids and molars (for the tooth chart, please see the entry on ???)

Fillings, both composites (white) and amalgam (silver) fillings can be just as tricky.  Some carriers will substitute the amount of coverage for a composite (white) filling for the amount of they have determined for a amalgam (silver) fillings, which is usually a lower coverage amount.

Other procedures such as crowns, bridges, veneers, perodontial preocedures may required pre-treatment xrays, which means your dentist/dental office would have to submit xrays of the area or tooth which needs to have one of these procedures performed BEFORE the work can be performed, otherwise your insurance may not pay!

So in conclusion, I woul like to leave you with these words of advice:

• CHECK YOUR DENTAL INSURANCE POLICY;
• KNOW YOUR DENTAL INSURANCE PLAN;
• Get a PRE-ESTIMATE ON ANY procedure you are unsure of what will be covered, or not; and
• And last but not least, when in doubt always SPEAK WITH SOMEONE at your dental insurance company with a pulse!