Ins and Outs of Dental Insurance

Note: The terms and explanations listed below are intended to provide patients with a general understanding of dental insurance and may not cover specific or unique benefits.

Insurance Terms:

  • Types of Insurance Plans
    • In-network – A Managed Care Plan where the dentist is contracted with a particular insurance company.
      • D-PPO – Dental Preferred Provider Organization type plans contract with multiple dentists to provide services at a lower fee to the patient. Many plans of this type will pay for “out-of-network” services.
      • D-HMO – Dental Health Maintenance Organization type plans require you to choose one dentist from a list of contracted dentists with the insurance company. This plan does not pay for out-of-network services.
    • Out-of-network – A Fee-for-Service plan where the dentist is not contracted with a particular insurance company and uses their own dental office’s fees or charges for each service.
      • NOTE: If a dental office is out-of-network for your insurance plan, this does not mean that an in-network dentist will give you lower out-of-pocket expenses. Check with the dental office to see if their fees fit within your insurance plan’s fee allowance.
  • Dental Procedure Code – Is an identification code for each dental service, determined by the American Dental Association.
  • Dentist “Fee-schedule” – List of dental procedures and prices. Click to learn more…
  • Insurance “Fee-schedule” – Price of procedures determined by your insurance plan. Your insurance plan prices may be different from your dentist’s.
    • Allowable UCR – “Usual, Customary, and Reasonable” Price – This is a fee determined by each insurance company, and can vary widely between insurance plans. Click to learn more…
  • Dental Claim – A claim is a bill sent by the dentist to the insurance company listing a patient’s completed procedures and their cost.
  • Annual Deductible – Yearly amount insurance companies require a patient to pay up-front before beginning coverage of certain procedures. Click to learn more…
  • Annual MaximumThe maximum dollar amount a dental plan will pay toward the cost of dental care within a specific benefit period (usually January through December). Click to learn more…
  • Managed Care Plan – see In-network.
  • Fee-for-Service – see Out-of-network.
  • Alternative Procedures/Benefits (Downgrades) –
    • If there is more than one acceptable option for a procedure, the insurance company will pay the amount for the least expensive one regardless of which option is chosen. This is called a downgrade. Filings and crowns are typically downgraded. Click to learn more…
  • “Summary of Benefits” Categories – Dental insurance procedures are divided into three categories, each having their own percentage of the patient’s co-payment.
    • Preventive/Diagnostic Procedures – Cleanings, exams, fluoride treatments, and sealants. Your insurance plan determines if X-rays are covered under Diagnostic or Basic procedures. Most plans do not require a deductible, but some do. Typical percentage of patient’s co-payment is 0-20%
    • Basic Procedures – Fillings (restorations), oral surgery (regular and surgical extractions), root canals, and gum treatments. A typical percentage of patient’s co-payment is 20-50%
    • Major Procedures – Crowns, bridges, implants, partials, and dentures. Typical percentage of patient’s co-payment is 50-75%. Some insurances may classify extractions, root canals, and periodontal treatments under Major and not basic.
  • Co-pay – The percentage of the procedure bill that the insurance company requires the patient pay the dentist before coverage. Click to learn more…
  • Explanation of Benefits – (EOB) – A statement by the insurance company showing what the dentist bills for each procedure, how much the insurance pays, and how much the patient pays.

Allowances & Fee Schedules

Alternate Benefits

Deductibles and Co-Payments

Annual Maximums

Explanation of Benefits