Confused about dental insurance for your child? At our Upper West Side pediatric dental office, we make the claims process easy. Our staff educates parents on the nuances of insurance policies and coverage, making sure there is no confusion about the cost of treatment and what you can expect from our practice.
Whether your child is a due for a cleaning, or is in need of more complex care, it is our goal to ensure you receive the most from your insurance benefits. If you would like more information, read on or call our office for assistance.
How Insurance Works – Making Dental Care More Affordable
A dental insurance plan is a contract made between either yourself or your employer and the insurance company. Both parties work together to agree on the amount your plan pays and what procedures are covered. When insurance is provided by your employer, your coverage is not based on what your child needs or what Dr. Lal recommends, but on how much has been paid into the plan. Employers commonly choose to cover some, but not all of their employees’ costs. If you are unsure whether the dental care your child requires is covered, our staff can help. You should let your employer know if you are not satisfied with the level of coverage offered under your insurance plan.
In-Network and Out-of-Network Pediatric Dentists
To provide the most amount of coverage for your child’s care, your insurance company may want you to choose a dentist from their list of preferred or in-network providers. These are dentists that have a contract with the dental benefit plan. Dr. Lal is in-network with the following plans:
• Aetna PPO
• Metlife PPO
• Anthem / Empire BCBS PPO
• Cigna PPO
• Guardian PPO
• United Concordia (Advantage Plus) PPO
• Delta Dental PPO
Your plan may have restrictions on the number of times certain visits will be paid for within a month or year. This is called a frequency limitation. To maintain proper oral health, your child may need to come to our office more often for routine care or follow up visits. With a frequency limitation in place, these additional visits are not covered.
We file most claims electronically, so your insurance company will receive them within days of the visit. If your insurance plan rejects a claim for any reason, we are more than happy to assist you in filling an appeal. However, you are responsible for any amount that remains once the claim has been paid as well as any balance left on the account after 30 days. We are glad to send a refund to you when your insurance pays us.
At this time, we do not accept any state-funded dental plans. If our practice does not participate with your insurance company, we are still happy to treat your child. Please contact Happy Teeth NY or call (212) 810-6562 to learn more about your out-of-network benefits.
A deductible is a specified amount of money that the patient must contribute annually before an insurance company will pay a claim. Most of the time, the deductible is not applied towards preventive services, such as routine dental exams and cleanings. However, just like your coverage, the amount of your deductible and the services it applies to are chosen by your employer or by the particular plan you purchased.
Example: Joe needs to have one of his baby teeth extracted (cost $100). His insurance plan will pay 80% ($80) after he has paid his $50 deductible. Joe’s mom or dad is responsible for his 20% co-pay ($20) and his $50 deductible.
Most insurance plans have an individual deductible and a family deductible. If the family deductible has been satisfied, you will not have to pay a deductible.
Example: Jada needs a baby root canal. Jada’s dental plan has a $50 individual deductible and a $150 family deductible. Her mother, father, and brother have all had dental treatment done within the year and have paid their $50 individual deductibles. Therefore, $150 has been paid towards the plan’s family deductible and Jada’s parents will not have to pay her individual deductible for that year.
What is A Co-Pay?
Your co-insurance or co-pay is the amount your insurance company will not pay. It is important that you are familiar with your insurance benefits, as we will collect the estimated co-pays at your child’s dental visits. We, at no time, guarantee what your insurance will pay on each claim.
Dual Pediatric Dental Coverage from Both Parents
In the insurance world, there is a special process that takes place when patients have more than one eligible dental plan, known as Coordination of Benefits (COB).
In these situations, even though your child is covered under two or more dental plans, there is no guarantee that these will pay for all of the services he or she needs. Each insurance company handles COB in its own way. For more details, check your plans or contact our office.
Bills (EOBs) from Your Insurance Company
After your child’s dental visit, you may receive an Explanation of Benefits (EOB) from your insurance company. Your insurance company sends these notices prior to claim payment to detail the services that were covered and how the claim was processed. Frequently, these EOBs reflect a patient balance owed and may look like a bill. However, if there are any outstanding amounts that need to be collected, you will receive either a statement directly from our office or a call from our staff to discuss what you owe. Until you are informed by a member of our team at Happy Teeth NY, please do not worry about the patient balance on your EOB.
Alternative Benefit Clauses
Your insurance plan may contain a LEAT (Least Expensive Alternative Treatment) clause. This means that if there is more than one way to treat a condition, your plan will cover only the least expensive option.
Example: John needs three fillings on his molar teeth. The best options are tooth-colored, mercury-free fillings, but his parents' insurance plan only covers silver fillings.
Disclaimer: We do not use amalgam (silver filling) material at Happy Teeth NY. If your insurance plan contains a LEAT clause, you may be responsible for additional co-pays.