There are many reasons a dental insurance might deny payment. It is important to remember that dental insurance is designed to help you pay for your care, but it was never intended to become the only way you pay for your dental care. Another important thing to remember is that if you have insurance through your workplace, your employer chooses the plan and what it covers. With those two thoughts in mind, let’s look at some of the common reasons that an insurance doesn’t pay:
Deductible: A deductible is the amount of money that you have to pay for your care before your insurance kicks in. To further complicate matters, some preventive procedures are not subject to the deductible. So you might be able to get your dental cleanings and check ups done but if you have a high deductible plan and need a filling, you might have to pay for that first filling out of your pocket. Until you have paid your deductible on applicable services, your insurance will not pay for your dental care.
Waiting Period: Some insurances will not cover certain services until you have had the plan for a certain amount of time. This seems to apply most often to fillings and major services. If you have treatment during the waiting period’s time, you have no benefits for that service. So if there is a particular reason why you are buying insurance (needing a crown, for example), check to see if there is a waiting period for that service before you buy the plan (or at least before you schedule)!
Exclusions: Almost all dental plans have certain services that they exclude from coverage, meaning that they will not pay anything for these procedures. Cosmetic services, such as teeth whitening, are a good example of this. Your insurance will not pay for a procedure that is excluded from your plan. Exclusions vary from plan to plan, so if you’re looking for insurance to help pay for a specific procedure (such as a dental implant), make sure to pick a plan that does not exclude them.
Limitations: Most dental insurances place limits on certain procedures. This includes how often they will pay for a service (frequency limitation) and reasons why a certain procedure can be performed. If your insurance specifies a frequency limitation of 2 dental exams a year, and you have 3, the insurance won’t pay for the third one. If your insurance says it will cover a cleaning once every 6 months, and you have your second one at 5 ½ months, the insurance will not pay for the cleaning. If your insurance will pay for a crown once every 5 years per tooth, it will not pay to replace your crown if it is 4 years old. If your insurance specifies that a tooth must have 3 surfaces filled in order to qualify for a crown, and you want to put a crown on an unfilled tooth, the insurance may deny payment (unless you and your dentist can show a really good reason for needing the crown that meets another criteria that the insurance company has in place.) Limitations vary from plan to plan, and sometimes you (and we) have to read carefully to find out what they are.
Exhausted Benefits: Dental insurances specify a maximum amount per year that they will pay toward dental care (most often $1,000-$2,000). Once the insurance has paid that amount, it will not pay any more until the next benefit year begins. One of the common beliefs we hear is that “I get two free cleanings a year.” Those cleanings might be “free” to you, but the insurance company picks up the cost for them. The cost is incorporated into that maximum amount per year. If you’ve already spent the maximum on other services, the insurance will not pay for your cleaning—you will (should you choose to schedule it).
For any dental services sent to insurance, both you and your dentist should receive a statement from your insurance company. That statement usually contains a message which will say why the payment was not sent. (If you have problems understanding it, call your dentist’s office or your insurance company to ask for an explanation.)
*Note: The information in this article is not meant to replace the clinical judgement of your healthcare professionals.
Dr. Jennifer Robb is a general dentist with a practice in Lorain, Ohio. She is currently accepting new patients. If you would like an appointment, please call 440-960-1940 or use the contact form at www.drjrobb.com to let us know your phone number so we may call you.