This month, I wanted to touch on an area that needs clarification. Many people call their respective insurance companies desiring a breakdown of their coverage. However, they fail to ask an important aspect of the coverage and that is whether or not it is based on a Calendar year (January 1st to December 31st), Benefit Period (e.g. July 1st to June 31st) or Rolling year. Rolling year is the most complicated of all because you need to ensure that you always count back 12 months from the exact date of the last treatment.
For further clarification, please contact our office.
March 2011
Frequency of Hygiene appointment or better known as "Cleaning appointment"
Many of you are on a 6 month routine for your dental hygiene appointment and have recently changed the frequency based on the information provided to you by your insurance company.
For example; you are notified by your employer or insurance company that your coverage has changed from 6 months to 9 month recare.
This is not always the case. In fact, this is misguided information. This is an attempt from the insurance company to save money and cut back on paid out claims. By eliminating details in your notification you are left assuming.
Let me try to explain:
Hygiene appointments are based on units of time (each unit represents 15 minutes). Your policy coverage should indicate the maximum number of units you are entitled to every year, not necessarily on a calendar year I'll address this issue at another time). How you want to use up these units of time is up to you not what your insurance company dictates.
In actual fact, a "recare" (terminology mostly used in the dental industry) refers to the examination performed by the dentist and is based on a 5, 6, 9 or 12 month interval. Therefore, you can maintain your cleaning as often as necessary (as long as you do not exceed the allowed units specified in your plan) and have your recare examination at every other appointment to eliminate rejected claims due to frequency limitations.
The solution to this problem is to check with your insurance company by asking the following questions:
How many scaling units do I have available or what is the maximum number of scaling units?
What is my recall exam limitation/frequency?
Should you require assistance with this, please do not hesitate to ask our admin team.
Your dental provider's recommendation of how often you should have your hygiene appointment is based on your needs and what is best for you, not what your dental plan covers. Most of all, take into consideration the importance of good oral health and do not let your insurance company dictate your choice of treatment.
February 2011
Replacement of Crowns and Bridges
Although crowns and bridges generally last longer than five years, in some cases, they may need to be replaced earlier. This can pose a problem as most dental coverage will not cover replacement of a crown or bridge if it is less than five years old. Generally speaking, most dental policies have guidelines or time frames as to when a replacement crown or bridge becomes eligible again. However, many insurance policies have left it open for interpretation, by putting nothing in writing or putting in as "reasonable and customary".
In the dental industry reasonable and customary usually refers to 5 years. However, if the insurance company does not clearly state this in writing, they have no grounds in which to reject a claim. If your claim is rejected based on a 5 year time line it can be appealed and won. All that is needed is a letter of appeal to the insurance company requesting to clearly state the page number and paragraph of such.
As a result, usually, a pay out the claim is made even if it is only 4 years old as they have no way of proving the time line of five years.
For more information and how to put together a letter of appeal, please contact our office.
January 2011
Dental Implant Coverage
How many of you have decided to change your dental treatment based on your dental coverage. For example; you need an implant but you have no coverage so you go with option B and get a bridge instead because you have some coverage for the bridge.
Although many policies state that there is no implant coverage, be aware that in some cases there actually is coverage. If you inquire with your insurance company, many policies have what is referred to in the industry as "Alternative Benefit Coverage." What this means is that if the dental treatment of choice is not covered (e.g. implant), then the insurance company is responsible to pay out the claim at the equivalent cost of an eligible alternative treatment (e.g. bridge).
You the patient have the right to choose your dental treatment without being dictated by your dental coverage. Also keep in mind that you have the right to appeal any rejected major claims. This is an area that is very complex for most patients, for more information please contact our office.
December 2010
Unused Dental Benefits
With the end of the year approaching, I should clarify that any of your unused dental benefits in any category; Basic or Major does not transfer to the following year. Many patients are with the understanding that as long as a pre-estimate has been completed and approved by the insurance company, they can do the treatment at any time and the cost transfers to the following year. This is not the case, treatment is billed on date of service and does not transfer no matter if it was pre approved or not. So if you have treatment needing to be completed, speak to our office how to maximize what is left of your plan. For further clarification please contact Maria.
November 2010
Maximizing Your Benefits: Two benefit years for Major work
As we approach the end of 2010, many of you are wondering how to maximize your dental plan and get the major dental work you require before the end of the year. Here is a tip on utilizing 2 calendar years for treatment.
Always remember that dental treatments are billed on the date of completion. Therefore, if you require major dental treatment that would consume your benefit plan (dollar amount) for that current year, you may be able to use your current year (dollar amount) and the upcoming calendar year (dollar amount) for that one sequence of treatments.
For example:
Someone needing root canal therapy and crown with a dental benefit maximum of $1000.00, you would get your root canal completed in December of the current year and then your crown in January of the following year. This maximizes two different benefit years and the tooth is completely treated.
There are many other scenarios so be sure to ask us.
Please contact Maria for further details.
October 2010
Accidental Dental Coverage
Did you know that most health care benefits package have an Accidental Dental Benefit? This is outside of your regular dental benefits and is usually covered under your health care package. Accidental Dental, covers most dental treatment at 100% even if it falls under major treatment such as crowns and bridges. An accidental Dental claim form must be submitted from you as well as a report from your dentist following the accident. Accidents can be as severe as falling down stairs or as simple as biting into a chicken bone. By using up this coverage you do not tap into your regular dental benefits and therefore leaving your regular coverage available for other dental services you may require. Policies vary so check your specific coverage.
Please contact Maria for more information on this topic
September 2010 Coordination of Benefits
Many patients are not aware of Coordination of benefits. This is when both husband and wife have dental and/or health coverage. You first submit claims to your own plan. Once you have received payment and it is anything less than 100% you then photocopy the explanation of benefits and send to your spouse's benefit for reimbursement of the difference. This also applies to dependants. However, this becomes a little more complex, as you must submit for each child to the parent's benefit plan, whose birthday comes first in the year. Contact Maria should you need more information.
by Maria Correia