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Blog on Children's Dental Health Care
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Dental Insurance Coverages and Dental Claims 

Tuesday, Apr. 23rd 2024 2:37 PM

Question: I have a dental PPO plan I got through my job. I need help understanding how my dental insurance states my coverages are one thing, but the numbers do not add up when a claim is filed. For example, I had a large filling and a crown not long ago. The filling coverages were to be at 80% paid. Which it was, so that was fine. However, the crown I got cost $1000.00, and my plan said that it paid out 50% of the cost of a crown. Straight forward math right, I should only have to pay $500.00, which was my co-payment of 50%. I then got the billing from the dental office stating the insurance company only paid $450.00, so my cost is $550.00. It is only $50.00 more, but this happens quite often. What should I do about this? 

Answer: In general, PPO plans to pay out a percentage of 80% for essential services such as fillings and 50% for major services such as crowns. But it does not just stop there. Usually, they will state that the percentage paid out is up to UCR (Usual, Customary, and Reasonable). Therefore, if the dentist you are going to is above the UCR rate for the company, you will have an additional charge. Also, some PPO plans will have two sets of coverage, one for network dentists and another for outside-network dentists. Outside-network dentists usually will have fewer benefits than inside-network providers. As to why you are paying more, I could not say which is the case for you. That will be something you should call your plan’s member services for. They can review your benefits and directly answer what is affecting your cost on claims. However, here is a tip you may want to keep in mind. Before starting any dental services, have your dental office submit to your insurance company as a quote only. That way, you will know the actual cost of dental care without worrying about additional expenses.

Posted by Carol | in Baby Dental Insurance, Baby Help | Comments Off on Dental Insurance Coverages and Dental Claims 

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