Confused about dental insurance for your child? Our Upper West Side pediatric dental office makes the insurance claim process easy. We educate parents on the nuances of insurance coverage so there is no confusion about what to expect from your provider or our office.
If your child is a due for a cleaning, or is in need of more complex care, read on or call on office for assistance.
How Insurance Works – Making Dental Care more Affordable
Dental insurance plans are a contract between yourself or your employer and the insurance company. Both parties agree on the amount your plan pays and what procedures are covered. Your dental coverage is not based on what your child needs or what their dentist recommends, but on how much your employer pays into your dental insurance plan.
Employers commonly chose to cover some, but not all of employees’ dental costs.
In-Network and Out-of-Network Pediatric Dentists
Your plan may want you to choose dentists from preferred or in-network providers, who dentists that have a contract with the dental benefit plan. Dr. Lal is in-network with the following dental plans:
• Aetna PPO
• Metlife PPO
• Anthem / Empire BCBS PPO
• Cigna PPO
• Guardian PPO
• United Concordia (Advantage Plus) PPO
• Delta Dental PPO
Your plan may restrict the number of times it will pay for certain visits. This is called a Frequency Limitation. Some patients may need routine care or follow up visits more often to maintain good oral health. These additional visits are not covered. If your insurance plan rejects a claim for any reason, we are more than happy to assist you in filling an appeal. However, any balances left on the account are the patient’s responsibility.
We file most claims electronically, so your insurance company will receive each claim within days of the treatment. You are responsible for any balance on your account after 30 days. We are glad to send a refund to you when your insurance pays us.
If we do not participate with your insurance company, we are still happy to treat your child. Please call (212) 810-6562 for information about out-of-network benefits. At this time we do not accept any state-funded dental plans.
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 amounts, 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 will not have to pay her individual deductible in the same year.
What is A Co-Pay?
Your co-insurance or co-pay is the amount your insurance company will not pay. You must be 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, the term that applies to patients that have more than one dental plan is Coordination of Benefits (COB).
Even though your child has two or more dental benefit plans, there is no guarantee that all of the plans will pay for the services he or she needs. Each insurance company handles COB in its own way. Please check your plan or contact our office for details.
Bills (EOB) from Your Insurance Company
After your child’s dental visit, you may receive an Explanation of Benefits (EOB) from your insurance company. Frequently, these EOB’s reflect a patient balance owed. Your insurance company sends these notices prior to claim payment. If there are any outstanding balances that need to be collected, you will receive a statement directly from our office or someone will call you to discuss the amount owed. If you’re not informed by a team member at Happy Teeth NY about any balance owed, please do not worry about the patient balance on your EOB.
Alternate Benefit Clauses
Your insurance plan may contain an LEAT (Least Expensive Alternate Benefit) clause. That means if there is more than one way to treat a condition, the plan will pay for only the least expensive treatment. In cases of cavities, the best option is typically a tooth-colored, mercury-free filling, but your insurance plan may only pay for silver fillings.
Example: John needs 3 fillings on his molar teeth. The best option in most cases is a tooth-colored, mercury-free filling but your insurance plan may only pay for silver fillings.
Disclaimer: We do not use amalgam (silver filling) material at HTNY. If your insurance plan contains an LEAT clause, you may be responsible for additional co-pays.