Understanding Your Benefits
As a dental practice, our commitment and priority is to provide you the best comprehensive care and treatment plan. As a courtesy, we'll file your claim for you, however any financial responsibility you might have is decided by your insurance company and your benefits. If we verify eligibility or plan benefits for you, this is still NOT a guarantee of coverage. Only when the claim is filed, will the insurance company make a final decision on how your claim will be paid based on the information on the claim and in your plan.
If we have received all your insurance information on the day of the appointment, we will be happy to file your claim for you. By law your insurance company is required to pay each claim within 30 days of receipt.
Please understand that we file dental insurance as a courtesy to our patients. We will gladly assist you in estimating your portion of the cost of treatment. However, we have no control over how your insurance company handles its claims or for what they pay on a claim. Unfortunately, your insurance company doesn't guarantee what they will or will not pay on each claim, therefore we are not able to guarantee your insurance payment(s).
How Are My Benefits Determined?
Covered Charges - These are services (also referred to as covered benefits) that are typically covered under the terms of your contract with your insurance company. It is important to note that even though services may be covered charges or a covered benefit, they are often subject to your deductible and/or co-insurance.
Non-Covered Charges - These are services that are not covered under the provisions of your insurance plan (these are policy specific). If your insurance does not cover a service you are responsible for the entire amount. As providers there is nothing we can do to reverse a non-covered charge.
Coinsurance - The amount that you are obligated to pay for covered dental services after you've satisfied any deductible required by your dental insurance plan. This is typically represented by a percentage of an eligible expense that you are required to pay. For an example, an 80/20 plan means the insurer pays 80% of the contracted rate on procedures while the insured will pay the remaining 20% of the contracted rate.
Deductible - This amount represents the amount the policyholder or patient must meet (pay) out of pocket before the insurer will begin to pay benefits. In many dental plans, preventive care visits will not be subject to the deductible, but most other procedures are subject to a deductible. Almost every plan has a deductible.
In Network - It is ultimately your responsibility to assure that you are in network; only you are aware of your insurance policy specifics. We have contracted with many insurance companies, however in recent years there have been so many changes, that we suggest you verify with your insurance.
Contracted Rate - This is the negotiated amount an insurance company has agreed to pay a provider for specific services subject to deductibles and co-insurance amounts.
What If I have Two Insurances?
When an individual(s), has two insurance policies, they are referred to as Primary and Secondary. This means that if an individual has insurance coverage for themselves, that is considered PRIMARY. If they also have insurance coverage through their spouse, this is considered SECONDARY. In NY state, in the case of dependents, the birthday rule applies. What the birthday rule means is that if both parents/guardians have insurance coverage for their dependents, the parent/guardian with the earliest birthday in the calendar year is PRIMARY. There is no choice - the birthday rule is the insurance rule in NY State. There is also no choice as to which insurance company we can submit claims to. NY State Insurance Law requires us to submit claims to all policies in effect.
How Do Primary and Secondary Pay?
An insurance claim is sent to the designated Primary insurance company for processing. They will pay according to the fee schedule. Once payment from Primary is received, our office will submit the claim, with a copy of the Primary EOB (Explanation of Benefits), to the secondary for processing. The secondary insurance company will pay according to their fee schedule, AFTER they see how much was paid by the Primary. It is a misconception, that individuals with two insurances will never have any out of pocket expense. In addition, it should be understood that the two insurances know about one another and they will never pay more than the submitted fees.
As a patient, you are responsible for knowing the provisions of your dental insurance plan (or plans), including which providers are in your network. We will work with you to help you understand your plan provisions, however, we strongly recommend that you review your description of coverage. It is important to understand your insurance plan benefits and coverage rules. Policies and coverage determinations may vary from year to year. Per your agreement with your insurance company you are responsible for your coinsurance at time of service as well as your payment for care not covered under your plan.