We are happy to file claims for all our patients with dental insurance. Please check your insurance company prior to your appointment with questions about eligibility, preferred or network providers and to determine your coverage & benefits.
Pediatric Dental Insurance
We are happy to file claims for all our patients with dental insurance. (If you have BCBS or Delta Dental, please refer to the “Insurance Networks & PPO’s” section below.) If your account has a balance after receiving payment from your insurance company, you will receive a statement in the mail. We ask that the balance be paid within 15 days.
Insurance benefits vary by plan. Please check your insurance company prior to your appointment for details on eligibility and your plan’s specific benefits, deductibles, co-insurance, uncovered procedures and the number of covered visits per year.
You must bring your insurance card to each appointment. If you do not have your card with you, we will ask you to pay for the charges incurred at that appointment. Please contact our office if you have any questions prior to your appointment.
Insurance Networks & PPO’s
(Preferred Provider Organizations)
Our office files claims and accepts direct reimbursement from all insurance companies. Please contact your insurance company prior to your appointment if you have any questions regarding Preferred Providers or Network Providers, and to also determine your coverage & benefits. While we are not currently under contract with any insurance network or PPO, we find that there is usually little difference in reimbursement from many insurance companies when patients see a dentist outside their network. We have found one medical plan
BCBS & Delta Dental
Patients with BCBS-NC and Delta Dental plans are now reimbursed directly from these two insurance companies. We ask these patients to pay for services in full on the day of the appointment. We will file your claim electronically on the day of your appointment and find that both carriers reimburse their subscribers within 2-3 weeks. Please check with your company before your visit to determine eligibility and benefits.
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Many dental plans also include orthodontic coverage. These benefits are separate from your dental benefits and are reimbursed differently. At Durham Pediatric Dentistry and Orthodontics we are happy to assist you to assure you receive the maximum benefit available to you. Please check your insurance company’s website, or contact your Human Resource department, to see if your plan includes orthodontic coverage. Prior to beginning orthodontic treatment you will also want to know your plan maximum, deductible, co-insurance and reimbursement schedule.
Orthodontic Payment Policies
We will assist you with filing your initial orthodontic insurance claim. However, we require all payments for orthodontic services to be paid directly to our office by the patient. We have several convenient and flexible monthly payment plans available for you to pick from. Your insurance company will then reimburse you directly throughout the course of treatment.
Interest Free Financing
Most of our orthodontic patients set up a monthly, no interest, payment plan to cover the orthodontic treatment fee. For your convenience, we can also set up automatic, monthly debits to your credit card or checking account. Discounts are available for patients who would prefer to pay in full at the beginning of treatment.
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How are the benefits of my dental plan determined?
The purpose of dental insurance is to help individuals by paying a portion of their dental care. Most dental benefit plans consist of a contract between an employer and an insurance company. For this reason, concerns about your dental plan should first be directed to your plan sponsor.
Just like health insurance, your dental benefits are determined by the cost and type of plan chosen by you or your employer. Unlike medical insurance, very few dental insurance plans pay 100 percent of any dental procedure. Our experience is that the average dental plan often pays 50 to 80 percent of the average total fee. The amount paid is usually determined by how much you or your employer pays for the coverage (the premium) and the type of contract set up with the insurance company.
What does the term “usual, customary, and reasonable fees” mean?
We have found that almost all dental insurance companies reimburse their subscribers at a rate lower than the dentist’s actual fee. This fee schedule is determined by each insurance company and is not based on what dentists actually charge. Frequently, insurance companies state that the reimbursement was reduced because “your dentist’s fee exceeds usual, customary, and reasonable (UCR) fee.” This gives the impression that any fee greater than the amount paid by the insurance company is “unreasonable,” or above what most dentists in the area charge for a specific service. This can be very misleading and is simply not accurate.
Each insurance company sets its own payment schedule and “allowable fees.” They do not take into consideration fees charged by dental specialists, such as pediatric dentists, orthodontists, endodontists, etc. These allowable fees may vary widely between insurance companies and are in place so that the insurance companies can make the profit they need in order to operate. In addition, insurance companies are not required to disclose to the consumer, or the dental professional, how they determine these fee schedules. In general, a less expensive insurance policy will use a lower reimbursement formula to determine their UCR fees.
Why was part of my child’s treatment not covered by my insurance plan?
One of the most frustrating issues to deal with is when an insurance company disregards the standards of care recommended by the ADA, the AAPD (American Academy of Pediatric Dentistry) and the AAP (American Academy of Pediatrics). In 2015 we began seeing a dramatic increase in the number of insurance companies who have reduced their reimbursement for routine, recommended procedures such as dental sealants, topical fluoride, and even white “tooth colored” fillings. Since we do not have information on the thousands of dental plans available, the patient ends up being responsible for knowing what exclusions and limitations are included in their plan.