A PPO, or Preferred Provider Organization, has a network of providers like an HMO; however, you don’t have to use the preferred provider. If you choose a provider that is not in the preferred network coverage is reduced but not eliminated completely. PPO dental plans have deductibles, copays, and premiums as well, and are often a bit more than HMO fees. Basically, you are paying more for the added choices and flexibility in the plan. Many people prefer the PPO dental plans because of the flexibility.

No, you can receive care from any dentist you choose. But remember, you will pay more if the dentist you choose is not a “preferred” provider.

No, it is not necessary to obtain a referral from your dentist to visit a specialist. However, it is always a good idea to discuss treatment options with your dentist before consulting a specialist. Also, be sure to request a predetermination of costs before treatment to know what your out-of-pocket costs might be.

Yes. Because in-network dentists accept our maximum allowable charges (MACs) as payment in full for covered services, there is no balance billing. This means your out-of-pocket savings may be greater when you choose a dentist that is in-network. In addition, discounts may be available for non-covered services and services exceeding the annual maximum.

Please note that discounted services are not insurance and payment is the member’s responsibility.

These are all terms that apply specifically to out-of-network claims for both your medical and dental plans.  All insurance companies use a national database that tells you what 8 out of 10 providers within a certain area are charging for services.  This national database takes into account that the cost of living and cost of services will vary by geographic region.

This NEVER applies if you are using in-network providers.  They MUST accept the insurance company’s payment in full (less any deductible or coinsurance you may be responsible for).  Out-of-network providers, however, can charge whatever they want.   No rules apply to them!

If you go out-of-network, then the insurance company will only pay the “reasonable and customary” reimbursement rate for that service.  If a member happens to be using a particularly expensive provider that is charging more than the “reasonable and customary” fees, then the member will be responsible for the deductible and coinsurance amount PLUS any charges in excess of R&C.

R&C (Reasonable and Customary) Example:

• An out-of-network dentist is charging $500 for a root canal.
• Your out-of-network benefits have a $50 deductible and 80% coinsurance.

If 8 out of 10 dentists in your local area are only charging $400 for root canals, then $400 is the “R&C” amount that the insurance company is going to reimburse your dentist no matter how much he or she charges you.  In other words, your dentist is charging $100 over the approved R&C amount – or $100 more than the “going rate” in your area! 

The Dental Claim Would Be Paid as Follows:

• The total root canal bill is $500. 
• The R&C amount for a root canal is $400.
• Deductible is calculated first:  $400 minus your $50 deductible= $350. 
• The insurance company will pay 80% of $350 ($280).
• You pay 20% of $350 ($70).
• You also pay the $50 deductible AND the difference between the total bill and R&C ($100).
• Your total cost would be $50 +$100 + $70 = $220.

Remember that R&C is never an issue as long as the employee uses in-network dentists.

Your Dental PPO is a national plan with contracted participating dental providers in all 50 states. You can find a list of these dentists on this web site. You can also call the 800 number on your Dental PPO ID card and ask a member services representative to guide you to a dentist near you.

Always remember to confirm with the dental office when you make your appointment AND before you receive services that they still participate with your dental PPO plan! DO NOT FORGET! It is your responsibility to make sure you are using in-network dentists if you want to receive in-network benefits!

If your dentist is not currently participating in the network, but would like to know more about the advantages of participation, please ask him or her to call your insurance provider using the number on your ID Card.

Yes. Just ask your dentist to submit a “pre-treatment estimate” – A pre-treatment estimate is a good idea if you are having extensive work done and want to know what your share of the cost will be. Also, you can find out if the procedures are covered, if you will exceed your annual benefit maximum, and how to best plan your payment portion.

Participating dentists will file claims for you. Non-Participating dentists do not have to file your claims for you. Some of them will and some of them will not – it really depends on the (out-of-network) dentist.

If the non-participating dentist will not file your claim, simply have them complete a standard American Dental Association (ADA) claim form or one of the Dental PPO claim forms on this web site, and you can submit the claim form along with your itemized bill to the claims department. The address for your dental claims department is on the claim form found in this employer benefits web site.

You can call member services toll free to check the status of a claim.

You can visit another dentist for a second opinion and you will be reimbursed according to your plan benefits. For maximum savings, visit a PPO network dentist.

You can call Member Services and request a new ID Card to be sent to your home. Some carriers allow you to print ID Cards from their member website. Be sure to verify the carrier has correct information on file such as addresses, telephone numbers, the correct members enrolled, and etc.

Your dental office just needs to know your name, social security number, group plan number and dental insurance company to call and verify benefits. Dental is not as complicated as medical and not having a dental ID Card isn’t a disaster like not having a medical or prescription card! Your claims will be processed correctly as long as the dentist office can verify your benefits with the insurance company.

All dentist’s offices work differently – so try one the following approaches:

1. Have the dentist try calling member services and identifying you with the social security number of the primary insured (primary insured will be the employee of the company providing your group health benefits).  Even if you do not have a card, they can usually verify benefits for the dentist based on the primary insured’s social security number and allow you to receive care.
2. Explain to the provider that an administrative update is needed in your insurance company’s system that will be corrected within 1-2 business days and have the provider file a claim (via the mail) with your POS Plan. By the time the claim form is received by your Dental PPO Claims Department, your specific information should be updated and the provider will be reimbursed according to the correct benefit level.  Remember that all insurance is tracked by the employee’s social security number and the employer’s group account number.
3. If the dentist will not do #1 or #2, then ask the dentist to send you a bill.  By the time you get the bill, your Human Resource Department can probably complete the administrative update and you can ask your doctor to re-file the claim with the insurance company. You can also wait for the bill and submit it to your insurance company and receive the money or have the money sent directly to the provider.
4. If the dentist will not do #1, #2 or #3, then you may have to pay out-of-pocket and file a claim form for reimbursement.  Again, if you ask your Human Resources Contact to correct your eligibility information, then the insurance company can process your claim quickly and reimburse you for your out-of-pocket expenses according to your specific benefit plan.

In all of these circumstances, make sure the Human Resources Contact notifies the insurance company to update / correct your information in their systems so that the claim gets paid correctly and so that the problem does not happen again.

• Call your insurance company first and ask the customer service representative to help you understand why the claim was paid incorrectly. 
• Make sure to write down the person’s name and ask them if your call is being tracked so that if you ever have to call again, there is a record of the conversation and the information they are giving you!
• Confirm that you and your family are enrolled properly (by your employer) into the insurance system (remember that Human Resources is ultimately in charge of providing the insurance company with correct eligibility information). If there is a problem with your basic enrollment information, contact Human Resources and ask them to correct it for you. 
• Once the administrative error is fixed, you can call the insurance company again (when they can see your correct information) and ask them to re-process your claim. 
• If there is no resolution after calling customer service, get copies of all related paperwork including claims, bills, collection notices, EOB’s (Explanation of Benefits) and anything else that is relevant.  Ask your Human Resources Contact or the Company Benefits Consultant to assist you with the problem.  Keep copies of EVERYTHING in case you ever have to contest a credit rating problem as a result of a collection issue. If you are proactive and address these issues right away, then 99% of the time the issue can be resolved before it goes to collection.

• Marriage
• Divorce or legal separation
• Birth or adoption of a child
• Death
• Spouse losing coverage at their place of employment
• Child losing coverage due to reaching the age limit. Open enrollment will occur once a year. Each year, you may change your benefit elections during the open enrollment period. Once you have made your selection, you may not change it until the next year’s open enrollment unless you have a “life changing event.” Life-changing events include:

You must notify Human Resources of your intent to change your benefit elections. Refer to your employee benefits website, benefit guide, or plan documents regarding the timeliness this must be completed (usually 30 days). Human Resources will need the reason for the change and the effective date of change.