Undestanding Dental Insurance

Our goal as dental healthcare providers is to ensure that you are offered the best dental care possible.  It is important to note that your dental benefits are not meant for recommending what kind of treatment you should have, and rather assist you in the treatment of choice.  

Navigating dental insurance plans can be tedious and difficult to understand, especially if you're using your benefits for the first time.  It's important to have at least an idea of your dental coverage ahead of a scheduled appointment, and it's even more important to acknowledge that your dental office may not have all of the answers for you, or any access to your personal benefit information without you present.  Here are some general pointers to help you understand your dental insurance plan:

 

What is the patient responsible for?

Patients are expected to cover the costs of any procedures that the insurance plan doesn't cover.  This may be services that are not covered at all by your insurance plan, or the portion of the procedure that you have agreed to pay.  This is also known as CO-PAYMENT.  Your agreement with your insurance company may be and 80%/20% for basic procedures like examinations, x-rays & restorative treatment, and 50%/50% for major procedures like crowns & dentures, however there are various other co-payment agreements that are possible.  Patients are expected to pay their co-payments on the date of service.  The more information you can provide for us about your insurance benefit plan, the more accurate we can be when taking payments.  See the "Additional Information" button below to download our insurance benefit worksheet.

Insurance plan limits

You insurance benefits will be limited to a specific eligibility amount per year (calendar or rolling months).  For example, your insurance benefits could have a MAXIMUM of $1200.00 CAD per year, per family member.  Your insurance benefits will also be limited to a specific fee guide as determined by your insurance company.  This fee guide may be different than that which our office follows, as it may be outdated.  The amount of coverage negotiated with your insurance company does not involve your dentist, therefore even if your insurance is 100% coverage, it is limited to the fee guide determined by your insurance company.  Our office follows the current Prince Edward Island Dental Association Fee Guide.

 

At our office, we are able to assign benefits to our office for most insurance plans.  This means that you will likely not be required to pay in full, up front for your treatment.  There are of course exceptions and some insurance plans require that you pay the dental office and be reimbursed.  

 

Electronic claims vs. Manual claims

Most insurance companies accept claims electronically, and some of those insurance companies will even respond immediately with a benefit estimate detailing how much of each procedure will be paid for.  Less frequently, but still common, some insurance companies require that we send manual claims that require your signature.  For most PRE-DETERMINATIONS, we must submit manually to include additional information necessary to approve coverage.  Pre-determinations are sent to your insurance company to request coverage for major procedures like crowns and dentures.

 

Primary and secondary insurance 

Some patients are covered under two insurance plans.  This can be two parents, or your own plan and a spouse's plan.  If you a new patient and your spouse/parents are not already patients of ours, we will require their names, address and birth dates in addition to the plan information.  

 

At the completion of your appointment, an electronic claim will be sent to your primary insurance.  If your primary insurance plan is covering less than 100% of the services, we will send a claim form to your secondary insurance to cover the balance.  Please make sure to check-out with our administrative team before leaving after your appointment as you will likely need to sign a manual form. As usual, a patient with DUAL INSURANCE is responsible for any balances not covered by both insurance plans.  This will likely be determined upon the receipt of payment from the insurance company(ies).

Insurance benefit cards

If you are covered by an insurance plan, especially if you are the plan holder, you will likely have an insurance benefit card.  This card contains the necessary information that we will need in order to process claims on your behalf.  See "Required Info" below for an idea of what your insurance benefit card may look like.

We ask that our patients bring their card to their first appointment, or as soon as possible when you have changed insurance plans.  In addition to your insurance benefit card, it is also very useful for us to have access to your plan specific information.  Due to privacy laws, we are unable to request this information from your insurance company and expect to receive it.  If your work or insurance company provided you with a benefit guide,  brochure, or otherwise, please also bring that with you to your first appointment.