Frequently Asked Questions • Dental
What is a DHMO?
A DHMO (Dental Health Maintenance Organization) is the dental equivalent
of a medical HMO plan. DHMO plans typically require participants
to select a Primary Care Dentist. Like a Primary Care Physician
(PCP), the Primary Care Dentist is responsible for the direction
and coordination of a participant’s dental care. Most DHMO
plans require that services be obtained from DHMO network providers
and typically do not pay a benefit for services rendered by non-network
providers.
My company offers a DHMO and a PPO. Which should I choose?
Your choice of dental plan is dependent on your personal
circumstances, provider requirements and willingness to
encounter out-of-pocket cost. Before making a choice, review the information
you were given about
your plan choices carefully. If you have an existing relationship
with a dental provider and that dental provider is not participating in
the DHMO
offered, you may want to consider participating in the
PPO. Dental PPO plans, like medical PPO plans, offer the opportunity of
obtaining care from either
network or non-network providers. Non-network UCR levels
are established by most insurance companies for services rendered by non-network
providers.
This means that a participant could be responsible for
additional costs if their provider’s service fees are higher than
the established UCR level.
How do I find out if my dentist is in the network?
There are several ways to determine if your dentist is
in your dental plan’s network. The best way is to consult the insurance carrier’s online provider directory. Provider directories can be found at most insurance carriers’ home website addresses. The provider directory found there is the most current reliable information. Website links to many insurance carriers can be found in the links section of this website. You may also contact your provider’s office or your insurance carrier’s
Member Services department.
Does my plan include any waiting periods?
Maybe. Each dental plan is different. It is very important
that you consult the plan summary documents that apply
to your plan. These documents will contain valuable information about
your benefits and should
answer this and other questions. You can also contact the
insurance carrier’s
Member Services department. They will be able to confirm
your eligibility and whether waiting periods apply to your plan.
What does UCR mean and how does it affect my plan?
If your plan includes a non-network option, then UCR limitations are more than likely built in. Regardless of whether your plan is a PPO or Indemnity, if you obtain services from a non-network provider you will encounter UCR.
UCR refers to Usual, Customary and Reasonable payment limitations imposed by insurance carriers on non-network service charges. UCRs are typically expressed as a percentage. UCRs govern and limit the fee an insurance carrier is willing to honor for services rendered and, as a percentage, reflect the number of providers in a given locale that are charging at or below the established UCR.
What is a Pre-treatment Review?
Many dental plans now either require or recommend that
participants request a pre-treatment review prior to beginning a course
of treatment
that is expected to exceed $200 to $250 (the amount is
dependent on your particular plan). A Pre-treatment Review is simply a
mock claim. Typically,
your dentist’s office would contact the insurance carrier and describe
the course of treatment and the services they expect to
render. The insurance company then reviews the services and course of
treatment and renders a
determination as to whether the services are covered under
the plan and the benefit payable for that service. A pre-treatment review
is not a guarantee
of benefits or payment on the part of the insurance carrier.
It does, however, provide invaluable advance information about the benefits
available under
your plan and may alert you to alternative courses of treatment.
When should I request a pre-treatment review from my insurance carrier?
Typically, you should request a pre-treatment review when your expenses are going to exceed $200. Since each dental plan is different, please refer to information specific to your plan.