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Do you Need A Dental Insurance Predetermination?

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That was tasty food but…ow! The bad news is something has happened to your tooth. You hurry to the dentist and during your check-up she recommends an extensive (and maybe expensive) treatment plan. The good news is that you have dental insurance. But don’t assume that coverage will be provided for any of the treatment plan. Before you put the dentist and your insurance to work, here is what you should do.

Get the treatment details in writing

Ask how much the treatment plan will cost. If your treatment will cost $300 or more you must ask your dentist for a written pre-treatment estimate before you get that dental work done.

Your insurer will use that information to conduct a predetermination. This no-cost service will help you

  • Know whether any or all of the dental procedures in the treatment plan are covered under your dental insurance
  • Understand how much of the treatment must be paid out of pocket, by you
  • Give you the opportunity to speak with your dentist to determine alternative treatments or procedures

Once you know from your insurer what is or is not covered, you can make an informed decision on your next steps.

How do you start the process?

Follow these steps to initiate a dental predetermination with your dental office:

  • Ask you dental office to complete either an electronic dental claim form or a paper dental claim form to submit to your insurer (your dentist will have the forms) with the treatment plan estimate.
  • Remind them to clearly mark the form as a predetermination request.
  • Let them know they may be able submit supporting documentation and dental x-rays online using your insurance provider’s portal..

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Your dental office will make the process as simple as possible for you once you request the dental predetermination.

You’ll receive a confirmation

After your dentist submits your treatment plan information your insurer will send you and your dentist a confirmation of treatment and costs.

The confirmation details your dentist’s specific treatment plan, what your benefits pay, and gives you an accurate out-of-pocket estimate.

Sometimes additional information may be requested by the insurer. Your dentist will supply any information you request, but it is your responsibility to ensure that you your insurer receives it.

What to do if your reimbursement is limited or declined

First, read the explanation from your insurer carefully. In most cases, it will explain how the benefit was calculated and it will identify any limitations or exclusions that have been applied. Look for language such as “Under the terms of your dental plan…”, “Your plan limits coverage to…” and “These services are covered only when…”.

These types of statements indicate that there are limitations within your contract and they have been applied to your claim. As a result, some or all of the costs associated with your treatment will remain an out-of-pocket expense not reimbursable under your plan.

For more detailed information about the specific provisions of your plan, consult your health insurance policy or talk to your provider.

Let us be your partner in your oral health

All dental treatment and care decisions should be made by you and your dentist based upon your actual needs. It is important to remember that your health insurance dental coverage doesn’t necessarily cover everything — but it is a very valuable tool for offsetting some or all of the costs of your regular and unexpected dental care. At SBIS our specialists are happy to help you understand your health and dental insurance options.

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