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Insurance FAQ’s


My dentist recommends a treatment that my plan will not pay for. Does this mean the treatment really isn’t necessary?

It is common for dental plans to exclude treatment that is covered under the company’s medical plan. Some plans, however, go on to exclude or discourage necessary dental treatment such as sealants, pre-existing conditions, adult orthodontics, specialist referrals and other dental needs. Some also exclude treatment by family members. Patients need to be aware of the exclusions and limitations in their dental plan but should not let those factors determine their treatment decisions.

My dentist recommends that I get a crown on a tooth, but my dental benefit will only pay for a large filling for that tooth. Which treatment should I have?

Some plans will only provide the level of benefit allowed for the least expensive way to treat a dental need, regardless of the decision made by you and your dentist as to the best treatment. Sometimes, special circumstances may be explained to the third-party payer to request an adjustment to this lower benefit allowance, but there is no guarantee that the third-party payer will alter its coverage. As in the case of exclusions, patients should base treatment decisions on their dental needs, not on their dental benefit plan.

My dental plan says that it will pay 100 percent for two dental checkups and cleanings each year. However, I just had my first checkup and cleaning, and the insurance company says I owe for part of the dentist’s charge. How can this be?

Plans that describe benefits in terms of percentages, for example, 100 percent for preventive care or 80 percent for restorative care, are generally Usual, Customary and Reasonable (UCR) plans. The administrators of UCR plans set what the plan considers to be a “customary fee” for each dental procedure. If your dentist’s fee exceeds this customary fee, your benefit will be based on a percentage of the customary fee instead of your dentist’s fee.


Exceeding the plan’s customary fee, however, does not mean your dentist has overcharged for the procedure. These plans pay a set percentage of the dentist’s fee or the plan administrator’s “reasonable” or “customary” fee limit, whichever is less. These limits are the result of a contract between the plan purchaser and the third-party payer. Although these limits are called “customary,” they may or may not accurately reflect the fees that area dentists charge. There is wide fluctuation and lack of government regulation on how a plan determines the “customary” fee level.


Question: “Do you take insurance as payment in full?”


Answer: While many offices do take insurance as payment in full, in the State of California, this is illegal. The state has investigators who check out various offices, and many dentists lose their licenses for engaging in this practice. They can possibly even go to jail if they do this on a wholesale basis. And while you may find some who will do it, they may be risking their careers.


You may be able to find some unethical dentists who will do this. Many of them will over-bill, pad the bill, and add extra charges to that insurance claim at the same time, but you’re putting yourself and the dental office at risk. You would be complicit in insurance fraud, a willing participant in committing a crime. If you and the other dental office are willing to take that risk, you may be able to find an unethical dentist who is willing to cooperate with you in committing insurance fraud.


What dental insurance covers

Not all dental plans are created equal, but a standard employer-provided PPO should cover between 80 and 100 percent of the cost for treatments like regular checkups, cleanings, fluoride and sealants. More critical work such as root canals or fillings are covered at anywhere from 70 to 80 percent, while major work like crowns or dentures typically come in at 50 percent coverage.


You also need to bear in mind the cost you’ll pay for each service. Dental plans come with a deductible each time you make a claim, which can range from $50 to $100. It’s possible to lower the amount you pay per month by increasing the amount of your deductible and visiting the dentist only once per year, but you run the risk of a huge bill if you suddenly need treatment. In addition, most plans have a maximum payout each year, often between $1000 and $2000. This seems like a substantial amount until you consider the costs of treatment: A periodic oral examination costs less than $100 on average, but a crown can cost between $700 and $800, while fixing a molar costs at least $600. As a result, your plan can quickly cap out.


Most plans cover 100% of preventive care. Preventive care usually includes an annual or twice yearly office visit for an exam, cleaning, x-rays and sealants. (NOTE: Sealants may be limited to certain age groups.)


Basic procedures are office visits for dental problems, extractions, fillings, root canals, and treatment for gum disease. You pay for part of these procedures as a co-payment, a set dollar amount (DHMOs) or co-insurance, a percentage of the cost (DPPOs and Dental Indemnity/ or Traditional Insurance).  A typical co-insurance amount is 80% or 70%. A DHMO policy will have a set dollar co-payment close to these percentages…


Major procedures are crowns, bridges, inlays, and dentures. They are usually covered at the highest coinsurance, such as 50%. DHMOs cover major procedures at a higher dollar co-payment. Root canals are also sometimes covered in this category rather than as a Basic procedure. So check your policy. Some carriers now cover implants under this category.



About half of dental PPOs, the predominant dental product in the market, have maximum annual benefit above $1500—half are less than $1500.  Deductibles for these products are usually between $50 and $100.  Some carriers now offer policies that roll some portion of an unused annual maximum over until the next year.  Whatever the annual maximum, only 4-7% of Americans (NADP Premium and Benefit utilization Trends Report, 2014—reflects 2013 data) with dental benefits hit their annual maximum.  This is a factor that employers weigh against the premium cost for higher annual limits.   NOTE:  DHMOs rarely have an annual maximum while most dental indemnity product annual limits parallel DPPO limits.


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Screen Shot 2016-02-19 at 2.41.54 PMSo you have dental insurance… why doesn’t it cover all your treatments?
When most people think of insurance they think of their medical insurance. The biggest benefit they have with this type of coverage is that medical insurance not only pays for wellness visits but its major purpose is to help defray costs when it comes to catastrophic illness or accident.
Enter dental insurance.. and while medical disease can be both unpredictable and catastrophic the majority of dental aliments are preventable. Preventative care including routine check-ups and cleanings are paramount to maintaining good oral health. If you regularly visit your dentist problems can be diagnosed early and treated without need for extensive, elaborate, or expensive procedures. That theoretically keeps the cost of dental care much lower than those of medical care.
So what really are the differences?
• Medial Insurance is designed primarily to cover the costs of diagnosing, treating, and curing serious illness or care in case of an accident. This usually requires a family practice physician, numerous specialists and a variety of tests administered by doctors and labs, multiple procedures may be required and the then there is the need for medication.
• Dental Insurance works differently. Most plans are designed to make sure that patients receive regular preventive care. High dental care rarely requires the complex multiple resources often required by medical care. Because most dental disease is preventable by routine care dental benefits are structured to encourage patients to get regular routine care.
• Medical Insurance usually pays for the majority of tests, operations, lab work etc. needed to diagnose and treat disease. The exception is some brand new technologies or experimental treatments.
• Dental Insurances are designed to cover only a portion of the total cost of a patients necessary dental needs when faced with treatment beyond the normal preventive care. For example your dentist may recommend a crown for a badly decayed tooth while your insurance may only pay for a filling, your dentist may recommend an implant for a diseased tooth but your plan will only pay for a bridge.
The second difference between the 2 types of insurance are important to expand on. If the patient has not maintained routine dental care and is now faced with extensive dental needs, they are presented with the choice- to accept the treatment planned as outline by their dentist and pay money out of their pocket to cover the treatment or only go forward with the treatment that is covered by insurance.
This leaves both the patient and the dentist in a bit of a pickle. The dentist wants to treat the disease that the patient is faced with so that it doesn’t get worse or cause any more serious problems. The patient on the other hand is asking the dentist to only preform those treatments that are covered by their insurance which may not be the preferred solution to the problem. Or they may have multiple teeth that require care and ask that only certain teeth are treated and then will wait until the next year’s dental benefits kick in.
The decision to not move forward with the recommended treatment usually leads to more extensive and expensive procedures. The patient may even be putting their health in jeopardy while delaying treatment. (this subject will be covered in upcoming posts)
The question you should ask yourself when making the decision to move forward with dental treatment not reimbursed by your dental plan is this, if you were presented with the fact that you had heart disease and your insurance did not pay for all of your treatment would you risk serious complications by only accepting the treatment covered by insurance or follow your physicians recommendation for treatment?
Maintaining a healthy mouth is important for a number of reasons. Many diseases such as diabetes, oral cancer and cardiovascular disease can be first detected in the mouth by a comprehensive oral exam. The team at Advanced Dentistry is committed to preventing dental disease before it becomes a major problem, and we are here for you if you are in need of more extensive treatment. We are a non-judgemental zone and improving your oral health is our mission.
While your eyes may be the window to your soul, your mouth is the gateway to optimal health and well-being.
Our staff is ready to help you with all you insurance questions, call us today 732 356-9120

Next week – frequently asked questions about dental insurance coverage.




The big game requires big snacks and to keep your pearly whites healthy we have posted 3 super snacks for the super bowl that are better for your teeth

Spicy Jalapeño Dip


What’s in it:

  • 1 16 oz. tub low-fat sour cream
  • 1 packet of Hidden Valley Ranch (or other brand) Fiesta Dip
  • 1 jalapeno, seeded and cubed

How it’s done:
1. Combine all ingredients in a blender and blend thoroughly.
2. Serve the dip with raw vegetables such as carrots and celery.

What makes it tooth friendly:
This dip with a kick will make your veggies disappear. Raw veggies require lots of chewing which stimulates and promotes healthy gums. Carrots contain beta-carotene that your body uses to create vitamin A which works to build strong teeth. The sour cream in this dip gives your teeth a boost of Calcium which also helps to keep your teeth strong.



Selecting a dentist is much more than looking up an office in the yellow pages. You need to find a doctor that meets your needs especially since continuity is key in maintaining good oral health. By regularly visiting the same dentist you build a partnership that involves both key ingredients- your needs and the dentist’s commitment to your care.

  • Reputation
    • Researching a potential dentist has never been easier. The internet allows for you to research what others are saying about the dentist and their practice. Today’s review sites have methods to weed out any “canned” or planted reviews allowing you to read real patients thoughts and recommendations. If others find them to be trustworthy and competent you should as well.
  • Education
    • Have they furthered their education by attending continuing education courses to stay on top of the latest trends in dentistry? By staying abreast of the latest techniques you can be assured they are able to offer you the best treatment options. Continue reading A DENTIST BY ANY OTHER NAME