Why doesn't my insurance pay for this?
UCR (Usual, Customary, and Reasonable)
Usual, customary, and reasonable charges (UCR) are the maximum amounts that will be covered by the plan. Although these terms make it sound like a UCR charge is a kind of standard rate for dental care, that is not the case. UCR terms are misleading for several reasons:
- UCR charges often do not reflect what dentists "usually" charge in a given area.
- Insurance companies can set whatever they want for UCR charges - they are not required to match actual fees charged by dentists.
- A company's UCR amounts may stay the same for many years - they do not have to keep up with inflation, for example.
- Insurance companies are not required to say how they set their UCR rates. Each company has its own formula.
So if your dental bill is higher than the UCR, it does not mean your dentist has charged too much for the procedure. It could mean your insurance company has not updated its UCRs, or the data used to set the UCRs is taken from areas of your state that are not similar to your community.
A dental plan may not cover conditions that existed before you enrolled in the plan. For example, benefits will not be paid for replacing a tooth that was missing before the effective date of coverage. Even though your plan may not cover certain conditions, treatment may still be necessary to maintain your oral health.
Coordination of Benefits or Nonduplication of Benefits
These terms apply to patients covered by more than one dental plan (for example, if you are insured by your employer and are also on your spouse's plan). Insurance companies usually want to know if you have coverage from other companies as well, so they can coordinate your benefits. For example, if your primary (main) insurance will pay half your bill, your secondary insurance will not cover that same portion of the bill.
A dental plan may limit the number of times it will pay for a certain treatment. But some patients may need treatment more often than that for best oral health. For example: a plan might pay for teeth cleaning only twice a year even though the patient needs cleaning four times a year.
Not Dentally Necessary
Each dental benefit plan has its own guidelines for which treatment is "dentally necessary." If a service provided by your dentist does not meet the plan's "dentally necessary" guidelines, the charges may not be reimbursed. However, that does not mean that the dental treatment was not necessary. Your dentist's advice is based on his or her professional opinion of your case. Your plan's guidelines are not based on your specific case. If your plan rejects a claim because a service was "not dentally necessary," you can follow the appeals process by working with your benefits manager and/or the plan's customer service department.