We accept Delta Dental, Cigna, PPO plans and plans that allow out of network benefits.
I am out of network, what will my insurance cover?
Coverage is plan specific not insurance specific. Most plans cover cleanings and regular checkups at 100%. Coverage level depends on if the insurance plan pays this percentage based on the doctor’s fee (provider’s fee schedule) or their own fee schedule often called a UCR (usual, customary & reasonable) fee schedule.
Copay examples for out of network coverage:
Scenario 1: Coverage at provider’s fee (doctors fee schedule)
Our cleaning fee is $100 and exam fee is $45. If your insurance plan covers cleanings at 100% of the doctor’s fee (provider’s fee schedule) you have no out of pocket expenses.
Scenario 2: UCR fee schedule lower
For example: Our cleaning fee is $100 and exam fee is $45. Your insurance plan pays 100% up to their UCR fee, which in this example is $90 for the cleaning and $40 for the exam. In this case your out of pocket would be $10 for the cleaning and $5 for the exam for a total of $15 out of pocket.
Scenario 3: UCR fee schedule higher
Many times the UCR fees are higher than our fees, which means there is no additional copay. For example: Our cleaning fee is $100 and exam $45. Your insurance plan pays 100% up to their UCR fee, which is $110 for the cleaning and $55 for the exam. In this case your out of pocket would be $0.
We are legally bound to collect copays. Insurances make it their business to assume we do. When out of network, the insurance company will not provide us with their UCR fee schedule, but will give this information to the patient. We are happy to guide you through the insurance plans and help you maximize your benefits. Give us a call at (908) 782-4521 or send us an email to firstname.lastname@example.org with questions. We are looking forward to hear from you.
Some helpful questions to ask when calling insurance companies?
- Do you reimburse at a UCR fee schedule or at the doctors fee schedule?
- What are the UCR fees?
- Have these codes ready when asking for the UCR fees:
- D0150 (Comprehensive exam) à new patients
- D1110 (cleaning)
- D0120 (exam) à periodic visits
- D0210 (Full mouth xrays series)
- D9944 (occlusal guard, night guard)
- D2330 (filling one surface, anterior/front)
- D2331 (filling two surface, anterior/front)
- D2332 (filling three surface, anterior/front)
- D2333 (filling four surface, anterior/front)
- D2391 (filling one surface, posterior/back)
- D2392 (filling two surface, posterior/back)
- D2393 (filling three surface, posterior/back)
- D2394 (filling four surface, posterior/back)
- D3310 (root canal anterior/front)
- D3320 (root canal premolar)
- D3330 (root canal molar/back)
- D2750 ( crown)
- D6065 (Implant crown)
- D6066 (Implant)
- Do you downgrade to amalgam for molars? If yes, what is the fee for amalgam fillings?
- How many cleanings do you cover per year? Are cleanings covered every 6 month or anytime in a calendar year?
- Is there a missing tooth clause?
- Is there a waiting period?