Insurance Q&A
Preferred Provider
"Preferred Provider" means we are In-Network for the following DENTAL plans:
Ameritas
Aetna
Humana
MCNA
Premier Life (aka Premier Access)
United Healthcare
EVEN AS AN IN-NETWORK PROVIDER, most "major" work still may require a co-payment.
Medicaid/Medicare
If you have Medicaid DENTAL coverage as a Pregnant Person or as a Child, you are most likely insured by either MCNA or Premiere.
Alternatively, if you are Blind, Disabled, Age 65 or older, OR are receiving treatment in a Substance Use Disorder Treatment Program, you are likely insured through The U of U School of Dentistry Network.
OUR CLINIC IS A MEDICAID/MEDICARE PROVIDER FOR ALL OF THE ABOVE. However, if you are receiving treatment in a Substance Use Disorder Treatment Program, your dental benefits must be activated prior to scheduling an appointment. Contact your case worker to complete the steps necessary to activate your benefits, otherwise we will not be able to treat you.
If you have Medicaid coverage but are NOT pregnant, blind, disabled, age 65 or older, or receiving treatment for substance abuse, you likely have EMERGENCY dental insurance. This only covers extractions when the tooth in question is causing a medical emergency. We consider these emergency extractions on a case-by-case basis and may choose to refer cases to other Medicaid clinics such as the 4th St Clinic or one of several clinics managed by the U of U School of Dentistry.
Out-of-Network Provider
We are not In-Network with BlueCross BlueShield, Cigna, Delta Dental, EMI, Guardian, or other insurances not listed above. As an out-of-network provider we ARE still able to file a claim with your insurance provider on your behalf. We instruct them to pay you directly, and we advocate for the highest refund possible. The balance for the day's treatment is due at the time of service unless otherwise negotiated.
Q: DO I HAVE TO HAVE INSURANCE?
A: Definitely not. We have competitive pricing so we can help you out whether you have insurance or not. The best measure in our clinic would be to sign up for our dental membership plan, which will cover all your exams, cleaning, whitening, xrays AND you will get 20% off any additional work you want/need done. You will never pay a deductible! Click the below button for more info.
Q: DO YOU “TAKE” MY INSURANCE?
A: The answer is Yes, but we may not be In-Nework (a Preferred Provider) for that insurance. An "In-Network" Provider has made an agreement with the insurance company to offer insured patients specific discounts. This means patients sometimes pay more to see an "out of network" dentist, but sometimes less, due to our competitive pricing. If we are Out-of-Network for your insurance, we will will file a claim with your insurance on your behalf. We instruct them to pay you directly, and we advocate for the highest refund possible. We believe our clinic has value for all patients regardless of insurance status. The cost differences are minimal relative to the excellence we will provide all patients.
Q: WHY AREN’T YOU A PREFERRED PROVIDER (PPO) FOR MY INSURANCE?
A: Unfortunately, some insurance companies simply do not pay dental providers enough to cover the cost of materials and labor for a procedure. If you’re having a hard time finding a dentist that “takes” your insurance, you may be covered by one of those low reimbursement companies, and it might be worth finding a new plan. We will still send a claim to your insurance, but you will have to pay the remaining balance if there is one.
Q: WHAT DOES PPO MEAN?
A: PPO means Preferred Provider Organization, and if your coverage says PPO, any dentist willing to do so can bill your insurance. This means you can choose to see whichever dentist you prefer. The insurance companies offer a list of "Preferred Providers," which are the "in-network" dentists who have signed a contract with them agreeing to their fee schedule (in other words the insurance decides the cost of each procedure). Remember this is only who the insurance prefers that you see. As a member of a PPO plan, you are free to see who you prefer, and dentists (in OR out of network) can file a claim on your behalf. That said, some dentists choose not to file ANY claims with ANY insurance.
Q: DOES THE DENTIST GET PAID BY THE INSURANCE COMPANY JUST FOR SIGNING UP TO BE A PREFERRED PROVIDER?
A: No. The patient and the insurance company receive the most benefit in a PPO situation. As a dental office, we’re just thankful to be on the list of in-network options for our patients with insurance. You could truly go anywhere for your care. We’re deeply honored each time a patient chooses us.
Q: I HAVE INSURANCE, SO WHY IS THERE AN OUT-OF-POCKET EXPENSE FOR MY TREATMENT?
A: Dental insurance generally offsets the cost of treatment, but often doesn’t pay for it entirely. On average, dental insurance covers 80-100% of preventive work (cleaning, exam and x-rays), up to 80% of basic (minor fillings) and up to 50% of major (crowns and bridges). We do our best to estimate your portion of the payment before you leave our office, but with dozens of insurance companies and thousands of individual plans it’s simply impossible for us to know all of them. That’s why it’s so important for you to know your plan and take charge of your health.
Q: I THOUGHT MY INSURANCE COMPANY WAS SUPPOSED TO COVER THIS. WHAT HAPPENED?
A: The term dental insurance is a bit misleading. Dental Insurance is more of a discount coupon book. The "insurance" you sign up for allows you to have a specific set of coupons that apply to different procedures and services. Sometimes it is a 100% off, sometimes it is a 50% off. Sometimes you don't have a coupon for what you need to have done. That is frustrating but is just the "coupon" set you or your employer have paid for.
Here are a few reasons why you may have received a bill:
Your insurance plan paid a lower percentage than expected for the procedure.
The treatment you needed was not covered by your plan.
The insurance company decided you did not need a procedure that the doctor identified as necessary or downgraded a procedure code.
You have not yet met your deductible.
You have not reached the end of your plan’s "waiting period" and are ineligible for coverage.
You’ve maxed out your plan (used up all your benefits on other procedures) and no longer have coverage until the plan resets next benefit period.
Q: HOW LONG DOES IT TAKE FOR AN INSURANCE CLAIM TO BE PAID?
A: The time for a dental insurance carrier to process an insurance claim varies. At least 38 states have enacted laws requiring dental insurance carriers to pay claims within a timely period (ranging generally from 15 to 60 days). If you want to file a complaint about a delayed payment, contact the insurance commissioner in your state. They want to know if your insurance company does not pay within the period allowed by your state law.
Q: THE DENTIST SAYS I NEED A CERTAIN PROCEDURE, BUT IT ISN’T COVERED BY MY INSURANCE. WHY NOT? ISN’T THERE SOME OTHER PROCEDURE THAT WOULD WORK JUST THE SAME?
A: We diagnose and provide treatment based on what you need, not based on what your insurance covers. Some employers or insurance plans exclude coverage for necessary treatment to reduce their cost. If you’re having trouble affording your dental care, ask us! We offer financing options and if the procedure allows, we can sometimes spread out treatment a little to help you afford it.
Q: WILL YOU CHANGE THE DATE OR PUT A DIFFERENT DATE ON MY PROCEDURE SO MY INSURANCE COMPANY WILL COVER IT?
A: No. This is insurance fraud. We are contracted with insurance companies to provide 100% honest information, otherwise our PPO relationship would be cancelled and our dental license revoked. Not to mention that we believe in providing honest, quality care because of who we are and what we believe. Dishonesty is never permitted in our office.
Q: WHAT IF I STILL HAVE QUESTIONS?
A: We will do our best to answer all of your questions, however, a call to your insurance company, a visit to their website or a meeting with your plan administrator (often your human resources department of your employer) is a great step to fully understanding your insurance coverage. We encourage you to learn as much as you can about your insurance and take charge of your health!
Q: I WANT TO TAKE CHARGE OF MY HEALTH! WHAT QUESTIONS SHOULD I ASK MY INSURANCE COMPANY/PLAN ADMINISTRATOR?
A: Your insurance company can provide you with a breakdown of your dental benefits, but there are six key things to ask about:
Plan Year: Does your insurance follow a normal calendar year? (Jan. 1- Dec. 31) If not, what month and day does your plan year start and end?
Deductibles/Yearly Maximum: What is your annual deductible? What is your family annual deductible? Does this apply to all family members or a limited number? What is your annual maximum benefit dollar amount?
Waiting Periods/Age Limitations: Are there any waiting periods for benefits to begin or age limitations?
Frequencies: How often does your plan cover cleanings, exams, x-rays, fluoride, and sealants?
Composite Restorations: Does your plan reduce coverage to the rate of old-fashioned amalgam restoration material or does it cover up-to-date composite fillings? Are there any other codes which are generally “downgraded” on your plan?
Percent Coverage: What percent does your insurance cover for:
Preventative/Diagnostic?
Basic Restorative?
Major Restorative Treatment and Prosthodontics?
Missing Tooth Clause: Does your plan cover replacement of teeth extracted prior to being on the plan?
Secondary Insurance: If applicable, does your secondary insurance policy have a non-duplication clause for dual coverage? If so, your second insurance may not help you unless you need a lot of dental treatment.
Once you have this information, bring it to us! It will help us understand your plan as well and help us better estimate your out-of-pocket expense.
Q: MY DENTAL INSURANCE HAS CHANGED. WHAT SHOULD I DO?
Go to the patient forms tab on our website and fill out the "insurance only" form. It is the second one down.
Q: I SAW A DIFFERENT DENTIST THIS YEAR. HOW DO I KNOW HOW MUCH DENTAL BENEFIT I HAVE LEFT THIS YEAR?
A: We highly encourage you to call your insurance company and ask. And be sure to let our business staff know about any dental appointments you have had at another office during the benefit year. This will help to ensure you receive your full benefit at upcoming appointments.