INSURANCE FAQ’s

• What insurance do you take?
  Most of our doctors are in-network with Delta Dental Premier. Any other insurance, as long as it is a PPO and is NOT an HMO/DMO, we can submit for you, and we fall in the out of network category of your benefits. Be sure when providing your insurance information that you are looking at your dental card, and not your medical card. If your card does not say dental on it, it is most likely medical. If you are unsure, you can always check with your HR department. Dr. Patrick Huynh is out of network with all Delta Dental insurance plans.

*** We do not participate in discount payment plans in our office ***

• What if I have an HMO/DMO plan?
  When you have an HMO/DMO plan, you are required by your insurance to go to an in-network office. We are not in-network with any HMO/DMO plans, and, therefore, we would not be able to submit anything to your insurance. If you still choose to come to our practice, we would love to see you! However, please, keep in mind that you will be required to pay out of pocket.

• What does it mean when we are “in-network”?
  We have a contract with this insurance provider. We have agreed to follow their fee guidelines, and do adjustments as they direct. They will cover the designated percentage of their contracted fee. Patients that go to an in-network provider usually receive a better benefit.
• What if I am out of network?
  Most plans have both an in and out-of-network breakdown of benefits. Your HR should have provided you with a breakdown of your benefits. That will show you percentages of coverage for both in and out of network. It would also show the differences in yearly maximum or deductible. Most plans typically pay Usual and Customary (UCR) or on a Fee Scale.
• What does it mean when my insurance pays Usual and Customary?
  When your insurance pays Usual and Customary (UCR), they have surveyed the fees in the area, and will pay based on the average. Our office typically falls within that range. If your insurance states they will pay 100% for a cleaning, it is usually a true 100%.
• What does it mean when my insurance pays on a Fee Scale?
  If you go to an out-of-network provider, and the insurance says they pay 100% for a cleaning, it is 100% of the insurance’s chosen fee, not 100% of our fee. Unfortunately, we cannot know what that fee is without sending a pre-estimate. For example, if we charge $100 for a cleaning, and the insurance Fee Scale is $75, and the plan pays 100%, they would pay $75 towards the cleaning, so the patient who goes out of network would be responsible for the difference of $25.
• What if I have Delta Dental PPO?
  We would be considered out of network with the Delta Dental PPO We can submit claims for you, but we would fall in the out-of-network category of your benefits. For example, if we are charging $100 for a cleaning and Delta Dental Premier discounts the fee to $90 (we adjust $10 off our fee) and the premier patient does not owe anything if their plan paid 100% of the $90. For PPO, the plan may only allow $80. Since you are using Delta Dental, we would still adjust the $10 off from the $100. You, however, would owe $10; the difference between the PPO and Premier. (Even if your plan states that you have 100% coverage)
• What if I have United Concordia?
  We have many patients who have UCCI. In order for us to submit claims, you must have their PPO plan. This is usually called Concordia Flex. UCCI is the one insurance company that will not send payments to us, but instead reimburses you as the subscriber. The patient pays our office in full at the time of service. We then submit the claim, and the patient typically receives reimbursement directly from UCCI within 10-14 business days. Payments, however, vary greatly with UCCI dependent on your specific plan.
• Will I owe a lot more if I come to your office and you are out of network? How much more will I owe?
  Some insurance plans are very comparable whether you go in, or out of network, where others are not. If you are changing plans, we would be more than happy to send a pre-estimate to your new plan once it is in effect, in order to let you know exactly what insurance will pay, and what your portion will be. A patient must be enrolled in a plan to send a pre-estimate.  It can take approximately two weeks to receive the estimate.
• What if I have a plan through the marketplace/exchange?
  There are many plans available through the marketplace. Unfortunately, it is impossible for us to know the parameters of your plan. We would advise you to call the customer service number on the back of your card to inquire more about your plan.
• How does insurance pay?
  Coverage is broken into categories: preventative, restorative, major, and endodontic. Preventative treatment usually includes cleanings, exams, and x-rays. Restorative includes fillings. Major includes treatment such as crowns and dentures. Endodontic treatment includes root canals. There is typically a yearly maximum to the amount of coverage on dental treatment and a yearly deductible on all treatment except preventative.
• What are questions I can ask my insurance to better understand my plan?
  • Can I go to an out-of-network provider?
  • If so, do you pay on Usual and Customary Fees, or a Fee Schedule?
  • If I go out of network, does my yearly deductible or maximum allowance change?
  • If I go out of network, do the percentages change on how my plan pays for procedures?
    • For example, do they cover 80% for fillings in-network, vs 70% out of network?
  • Do I have different coverage levels at an out-of-network provider?
  • Do I have an amalgam downgrade for posterior teeth? – This is when insurance pays for silver fillings instead of white. Our office only provides white fillings.

• I am looking to get dental coverage. What are some things I should look for in a plan?
  • How much is my yearly allowance?
    • $1000 is typical; some have $1500, or $2000.
  • How much is my deductible? Does it apply to preventative care?
  • Is there a waiting period for any services?
  • Is there a missing tooth clause?
    • A missing tooth clause applies to teeth that were missing prior to obtaining coverage. The insurance will not cover to replace it. This includes a bridge, implant, or partial.