Payment Options

Many insurance carriers refer to their allowed payments as UCR, which stands for usual, customary, and reasonable. However, usual, customary and reasonable often doesn’t mean exactly what it seems to mean. UCR is actually a listing of payments for all covered procedures negotiated by your employer and the insurance company. This listing is related to the cost of the premiums and where you are located in your city and state. Your employer has likely selected an allowed payment or UCR payment that corresponds to the premium cost they desire. UCR payments could more accurately be called negotiated payments.

In most cases, there is always a portion that is not covered by your dental insurance plan.

Even a benefit plan that does not cover a large portion of the cost of needed dentistry pays something. Any amount covered, reduces what you have to pay out of pocket, so it does help!

Remember that what insurance carriers call “usual and customary” is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment. It is usually less and frequently much less than what any dentist in your area might actually charge for a procedure. It does not mean that your dentist is charging too much.

Usually the dentists on the list have agreed to a contract with the benefit plan. These contracts have restrictions and requirements. If you choose a dentist on the list, you typically will pay less toward your dental care than if you choose a dentist that is not on the list. If your dentist is not on the list, this does not mean that something is wrong with the dentist or office.

They do this to save money. Many dental plans allow a benefit only for the least expensive method of treatment. For example, your dentist may recommend a crown. With your insurance only offering a benefit towards a filling. This does not mean that you have to accept the filling. The good news is that some benefit will be paid; the bad news is that more of the fee will be your responsibility. Remember that your dentist is responsible for prescribing the treatment that is best for you. The insurance carrier is mainly interested in controlling payments.

Your plan contract specifies how many of certain types of procedures it will consider annually. It limits the number of x-rays, cleanings, and gum treatments it will cover because these are the types of treatments many people need to have frequently.

State laws regulate these issues. It is insurance fraud to change the dates of service on a claim. Both the patient and dentist can be prosecuted.

Because your insurance coverage is between you, your employer, and the insurance carrier, your dentist does not have the power to make your plan pay. If your insurance doesn’t pay, you are responsible for the total cost of treatment. Sometimes a plan may pay if patients send in claims for themselves. The Employee Benefits Coordinator at your place of business may also be able to help. Consumers (patients) may also lodge complaints with the State Insurance Commissioner.