Dental Insurance FAQ's

What is a “UCR” and how is it determined?

“UCR” is the term used by insurance companies to describe the amount they are willing to pay for a particular procedure. There is no standard fee or accepted method for determining the UCR, and the UCR has no relationship to the fee charged by your endodontist. The administrator of each dental benefit plan determines the fees that the plan will pay, often based on many factors including region of the country, number of procedures performed and cost of living.

Why was my benefit different from what I expected?

Your dental benefit may vary for a number of reasons, such as:

• You have already used some or all of the benefits available from your dental insurance.
• Your insurance plan paid only a percentage of the fee charged by your endodontist.
• The treatment you needed was not a covered benefit.
• You have not yet met your deductible.
• You have not reached the end of your plan’s waiting period and are currently ineligible for coverage.

Why isn’t the recommended treatment a covered benefit?

Your endodontist diagnoses and provides treatment based on professional clinical judgment and not on what treatment is covered (or not covered) by your insurance carrier. Some employers or insurance plans exclude coverage for necessary treatment as a way to reduce their costs. Your plan may not include this particular treatment or procedure, although the doctor may deem the treatment necessary.

How do I know what my payment portion will be if my insurance does not cover the entire fee?

Your payment portion will vary according to the UCR of your plan, your maximum allowable benefit and other factors. Ultimately, the patient portion is not known until the insurance carrier pays the claim.

How do I understand my Explanation of Benefits (EOB)?

Your Explanation of Benefits (EOB) is a wealth of information. The EOB identifies the benefits, the amount your insurance carrier is willing to pay, and charges that are and are not covered by your plan. The statement includes the following information: UCR, co-payment amount/patient portion, remaining benefits, deductible and benefit paid.

How long does it take for a claim to be paid?

The time for a dental insurance carrier to process an insurance claim varies. At least 38 states have enacted laws requiring dental insurance carriers to pay claims within a timely period (ranging generally from 15 to 60 days). On average, most insurance carriers will issue claim payment within roughly 30-days of receipt of claim. If you want to file a complaint about a delayed payment, contact the insurance commissioner in your state. They want to know if your insurance company does not pay within the period allowed by your state law.