Why Doesn’t My Dental Insurance Pay for This?

No Comments

Questions about Dental Insurance in South Jersey?


Do you have dental insurance in south jersey and wondering how it works? In this article, you will learn key terms that describe the ways you share dental costs with your benefits plan.


We will also give you examples of when you may have to pay some or all of your treatment costs. We will also discuss why it’s important to make treatment decisions with your dentist and based on what’s best for your health.


Rapha Dental provides cosmetic and family dentistry South Jersey, we take most PPO insurances.

What is a Dental Benefit Plan?


In this article, you will learn key terms that describe the ways you share dental costs with your benefits plan.

Dental benefit plans are designed to cover (pay for) some of the costs of dental treatment. Even though most people refer to the plan that pays for their dental care as “insurance.” But it’s technically a different type of health plan. Deal benefit plans function differently than most health insurance plans. Your dental benefit plan may only cover some procedures fully. For example, regular check-ups and cleanings. It may cover some procedures partially, may not cover certain procedures at all. You should know what your dental plan covers and what it doesn’t.


A dental benefit plan can make it more affordable to get the dental care you need. However, dental benefits should not be the only thing you consider when deciding on your treatment. Ultimately, you should determine your treatment based on your health needs, not by your level of dental coverage.


How Dental benefit Plans Work?


Dental benefit plan will not cover every dental procedures. Plans usually cover some, but not all, of your dental costs and needs.

Many plans involve a contract between your employer and a dental plan provider. But you can also buy individual dental plans on your own. You can also do that through the health insurance market places.

Your dentist do not determine your dental coverage

Your dentist’s primary goal is to help you maintain good dental health. But insurance will not cover every procedure your dentist recommends. It is important to understand what is covered and how much you will pay to avoid surprises on your bill.

Your dental coverage has nothing to do with what you need or what your dentist recommends. How much you or your employer pays toward plan will determine that. Sometimes, your plan may not cover anything you need. Many plans do not cover cosmetic procedures.

(Rapha Dental provides cosmetic and family dentistry South Jersey, we take most PPO insurances)

Key Terms for Understanding Coverage


Your dental insurance in south jersey shares treatment costs with you. It means that they may pay part of the cost and you will pay part of the cost. There are certain cost control measures that dental benefit plans use to share treatment costs with you. Here are some key terms that are used to describe these measures.



A deductible is the amount of money that you must pay before your benefit play will pay for any service. It can take more than one service or visit to meet your deductible. Most plans dont’ require a deductible for diagnostic services such as exam, x ray, preventive services.



In most cases, after you meet your deductible, you will be expected to pay a percentage of the allowed benefit amount of a covered dental service. They call it coinsurance. This type of cost sharing is common in preferred provider organization (PPO) plans which are most popular type of dental benefit plans.

For example: Your plan may pay 80% and you pay the remaining 20% of the plan’s allowed fee to your dentist. If your plan’s allowed amount was $100, your plans pays $80 and you would pay the remaining $20.


Annual maximum

An annual maximum is the maximum dollar amount a dental plan will pay during the year. Your employer decides the maximum levels of payment in its contract with the dental benefit provider. You would pay for anything over that set dollar amount.

If the annual maximum of your plan is too low to meet your specific needs, you may want to ask your employer to consider a higher annual maximum. If your plan also covers braces and orthodontics, there is usually a separate lifetime maximum limit.


Pre-Existing Conditions

Your dental plan may not cover conditions you had before enrolling-called pre-existing conditions. Even though you need the treatment. You are responsible for paying these costs.

For example: If you had a missing tooth before the effective date of your coverage, benefits will not pay for replacing the tooth. Even though your plan may not cover certain conditions, you might still need treatment to keep your mouth healthy.

Coordination of Benefits (COB) or Nonduplication of Benefits

These terms apply to patients covered by more than one dental plans. For example, a plan from your employer and one from your partner’s employer. The benefit payments from all plans should not add up to more than the total charges. Even though you may have two or more dental benefit plans, there is no guarantee that all of the plan will pay for the services you need. Each dental plan handles coordination of benefits in its own way. You should check your dental plans for specific details.


Plan Frequency Limitations

A dental plan may limit the number of times it will pay for a certain treatment. But, you may need a treatment more often to maintain good oral health. Make treatment decisions based on what’s best for your health, not just what is covered by your plan.

For example: Your plan might pay for teeth cleaning twice a year. But if you need teeth cleaning four times a year, you would pay out of pockets for the extra 2 cleanings.


Not Dentally Necessary

Many dental plans state that only procedures that are “medically or dentally necessary” will be covered. If the claim is denied, it does not mean that the services were not necessary. Employees at the benefits provider make decisions that do not take into considerations the clinical judgement of your dentist. Treatment decisions should be made by you and your dentist.

If your plan rejects a claim because a service was “not dentally necessary,” you can appeal. Work with your employers’ benefits manager and the dental plans’ customer service department or your dental office to appeal the decision in writing.


Other Cost-Control Measures from dental insurance in south jersey


Procedure Bundling

Dental plan combines two different dental procedures into one procedure. For example, a plan may combine the payment for a core buildup with a crown. This may reduce your benefit.


Down Coding

When a dental plan changes the procedure code to a less complex or lower cost procedure than was reported by the dental office. For example, a plan may only pay for silver colored filling or metal crown instead of tooth colored material. This may reduce your benefit.


Least Expensive Alternative Treatment (LEAT)

If there is more than one way to treat a condition, the plan will only pay for the least expensive treatment. However, the least expensive option is not always the best option.

For example, your dentist may recommend an implant for you, but the plan may only cover less costly dentures. You should talk with your dentist about the best treatment option for you. It is important that you understand the coverage provided by your plan and your payment responsibilities to your dentist.


Non Covered Procedures

Some procedures may be excluded from coverage under the plan.



How Do I Find Out What Is Covered?

When you sign up for your dental coverage, your dental benefit plan provider should include a benefit plan summary. The plan summary should include a list of covered services and information about the deductible, coinsurance, annual maximums, reimbursement levels, estimated cost share, limitations, and exceptions. Check with your plan provider to find out what is covered through your dental benefits.


Make Your Dental Health the Top Priority.

Although you may be tempted to make decisions about your dental care based on what your dental plan will pay, remember that your health is the most important thing. Talk with your dentist to make sure you are getting the treatment you need.


Looking for a dental office that takes dental insurance in south jersey?


Rapha Dental provides cosmetic and family dentistry South Jersey. If you have questions about how dental insurance works, please give us a call at 856-829-8668.

Here is the link for insurances we take.

You can make an appointment yourself on line. We look forward to meeting with you.


Copy Right to American Dental Association

Dr. Huh is member of American Dental Association