How 2 Group Plans Or 1 Group And 1 Individual Plan Can Coincide

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It’s a big relief to find out that the new job comes with dental coverage. Finally, you can make that appointment you’ve been putting off!

But even if your employer doesn’t offer coverage, it’s a good idea to seek out dental insurance. Unexpected issues arise all the time; it’s better to have a plan already, so you won’t have to worry. Even better, if your spouse has a plan of their own, you may have double coverage!

There are situations where one dental plan may not completely cover a procedure, and a spousal plan might take up the slack. When there are two insurance plans, and you are filing your claims to both, you must submit them in a certain order. This process is called “Coordination of Benefits” according to the Canadian Life and Health Insurance Association.

What You Need to File for Dental Claims

After you receive your dental treatment, your claim goes to your insurance provider. Your dental office may be able to submit your application electronically on your behalf, but first, please ensure they know you have more than one plan.

If you send the claim yourself, you will need to provide a standard dental claim form.

This form should include the following:

  • a list of the procedures performed
  • the corresponding codes for each procedure
  • the monetary amounts per code and total cost
  • the dentist’s name and contact information,
  • the patient’s name
  • the date of service, and
  • your policy number and personal information.

You will always require this standard dental claim form when submitting dental claims. Remember that if you have two plans, you will need to provide a copy of the form to both.

Whose Plan Pays First?

There are very specific rules in place when you have two insurance plans. You must follow the procedures carefully to avoid a refusal or request for more information. If you are the patient receiving dental treatment and you have your own plan, you must file to that plan first.

Several factors will affect your claim, such as

  • the percentage at which your plan will cover the services
  • whether your plan has a deductible
  • whether your dental office charges above the standard fee schedule
  • whether the procedure is eligible for reimbursement under your plan, and
  • whether you have reached your plan maximum for the year.

Once your program has assessed your claim, you will receive an Explanation of Benefits (EOB) that will outline what your plan paid, the percentage it paid, and any information about why they paid that particular amount.
Once you have the EOB, you must send the original statement to your spouse’s plan along with a copy of the standard dental claim form outlining your name, the dentist’s name, the codes of the services rendered, the costs, and your own dental plan information along with your spouse’s signature. It’s important that your spouse’s plan is aware that you have coverage of your own.

This system works in the reverse direction when claiming your partner’s services under your plan. His or her application must go through their program first, and you will need to send a copy of the dental claim form along with the original EOB from his or her plan.

When the secondary program assesses your claim, you will receive an EOB from them explaining what they paid and why. If there is still an outstanding amount after your application is sent to both plans, you will be responsible for those charges.

Who’s Plan Do You Claim with First for Dependent Children?

Determining whose plan pays first can be a little tricky. Your dependent children’s claims must be sent to the plan of the parent whose birthday comes first in the year. Remember, this doesn’t apply to whoever is older, it goes by date.

If you share a birthday with your partner, it will be determined by whose name comes first alphabetically. If you are still unsure, try calling your insurance provider for clarification.

In the event of a divorce, these rules still apply, however, this may be subject to change if a court order demands that one plan pays first due to custody arrangements.

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Will My Plan’s Deductible Be Reimbursed?

Suppose the first plan has a $25 deductible, and you submit a claim. The deductible will be applied, and you will be out of pocket for that amount unless you present the claim to a second plan as well. When you submit to the second policy, your $25 is reimbursed at the eligible percentage.

If however, your second plan also has a deductible, it may be taken off, and you won’t recoup the $25 from your other plan. It will be considered, but because of the second plan’s deductible, your payment is affected accordingly. Situations such as these can be a little confusing, but remember that deductibles are a normal aspect of dental plans and you are expected to pay it every year.

The Canadian Dental Association also shares a few tips on how to proceed with your dental claims.

Coordinating benefits between two plans can certainly be confusing, and sometimes mistakes are made. Your benefits provider can be your greatest source of information.

If you are unsure how to proceed, give them a call and find out what you need to do to receive your full entitlements and how to move forward in the future for your dental claims. After all, twice the coverage doesn’t have to mean twice the headache.


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