At Willow Pass Dental Care we make every effort to provide you with the finest care and the most convenient financial options. To accomplish this, we work hand-in-hand with you to maximize your insurance reimbursement for covered procedures. If you have any problems or questions, please ask our staff. They are well-informed and up-to-date. They can be reached by phone at 925-680-4444. Please call if you have any questions or concerns regarding your initial visit. Please bring your insurance information with you to the consultation so that we can expedite reimbursement.
For your convenience, we accept all major credit cards, cash, money orders and personal checks. For patients desiring financing, please check our financing options.
We deliver the finest care at the most reasonable cost to our patients, therefore payment is due at the time service is rendered unless other arrangements have been made in advance. If you have questions regarding your account, please contact us at 925-680-4444. Many times, a simple telephone call will clear any misunderstandings.
Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.
We will send you a monthly statement. Most insurance companies will respond within four to six weeks. Please call our office if your statement does not reflect your insurance payment within that time frame. Any remaining balance after your insurance has paid is your responsibility.
Why doesn’t my insurance pay for treatment?
Employers offer dental benefits to help employees pay for a portion of the cost of their dental care. Dental plans are designed to share in the cost of your dental care, not to completely pay for those costs. Almost all dental benefit plans are the result of a contract between the plan sponsor (usually an employer or a union) and the third-party payer (usually an insurance company). The amount your plan pays is determined by the agreement negotiated by your employer with the insurer. Your dental coverage is determined not by your dental needs but by how much your employer contributes to the plan.
Usual, customary, and reasonable charges
Usual, customary, and reasonable charges (UCR) are the maximum amounts that will be covered by the plan for eligible services. The plan pays an established percentage of the dentist’s fee or pays the plan sponsors customary or reasonable fee limit, whichever is less. Although these limits are called customary, they may or may not reflect the fees that area dentists charge. Exceeding the plan’s customary fee, however, does not mean your dentist has overcharged for the procedure. Why? There are no regulations as to how insurance companies determine reimbursement levels, resulting in wide fluctuation. In addition, insurance companies are not required to disclose how they determine usual, customary, and reasonable charges.
Most dental programs have an annual dollar maximum. This is the maximum dollar amount a dental plan will pay toward the cost of dental care within a specific benefit period, usually the plan year. The plan purchaser/employer makes the final decision on maximum levels of reimbursement through the contract with the insurance company. The patient is usually responsible for paying COT above the annual maximum. Your employer may want to research plans that offer higher annual maximums when assessing how to better meet the needs of employees.
Just like medical insurance, a dental plan may not cover conditions that existed before the patient enrolled in the plan. This includes plans that have a missing tooth exclusion. Benefits will not be paid for replacing a tooth that was missing before the effective date of coverage. Even though your plan may not cover certain conditions, treatment may still be necessary.
A dental plan may not cover certain procedures or preventive treatments. This does not mean that these treatments are unnecessary Patients need to be aware of the exclusions and limitations in their dental plan but should not let those factors determine their treatment decisions. Your dentist can help you decide what type of treatment is best for you.
Coordination of benefits and non-duplication of benefits
Coordination of benefits (COB) is a method of integrating benefits payable for the same patient under more than one plan. Benefits from all sources should not exceed 10O% the total charges.
Plan frequency limitation
Certain procedures may simply not be covered as often as necessary for optimal oral health. A common example might be a plan that pays for tooth cleaning only twice a year even though the patient requires cleaning every three months. Limitations may vary depending on the contract purchased. Limitations in coverage are the result of the financial commitment the plan sponsor has agreed to make and the benefits the third-party payer will offer for that commitment.
Not dentally necessary
The plan provides benefits for those services and materials that it considers to be dentally necessary and meet generally accepted standards of care. Based on the information your dentist submits, the service may not appear to meet plan criteria, and no benefit may be allowed. This does not mean that the services were not necessary. You or your dentist can appeal the benefit decision by submitting relevant information. The claim, along with the submitted information, should be reviewed by the plan’s dental consultant which the procedure code has been changed to a less complex and/or lower cost procedure than was reported except where delineated in contract agreements.
Least expensive alternative treatment
he dental plan may only allow benefits for the least expensive treatment for a condition. As in the case of exclusions, patients should base treatment decisions on their dental needs, not on their dental benefit coverage. In many instances, the least expensive alternative is not always the best option. You should consult with your dentist on the best treatment option for you.
Explanation of benefits (EOB)
An EOB is a written statement to a beneficiary, from a third-party payer, after a claim has been reported, indicating the benefit/charges covered or not covered by the dental benefit plan In those instances where the plan makes partial payment directly to the dentist, the remaining portion for which the patient is responsible should be prominently noted in the EOB. Any difference between the fee charged and the benefit paid may be due to limitations in the dental plan contract. Typical information reported on an EOB includes:
- the treatment reported on the submitted claim by ADA procedure code numbers and nomenclature; and,
- the ADA procedure code numbers and nomenclature on which benefits were determined.