“UCR” is the term used by insurance companies to describe the amount they are willing to pay for a particular endodontic procedure. There is no standard fee or accepted method for determining the UCR and the UCR has no relationship to the fee charged by our office. The administrator of each dental benefit plan determines the fees that the plan will pay, often based on many factors including region of the country, number of procedures performed and cost of living.
Your dental benefit may vary for a number of reasons, such as:
- You have already used some or all of the benefits available from your dental insurance.
- Your insurance plan paid only a percentage of the fee charged by our office.
- The treatment you needed was not a covered benefit.
- You have not yet met your deductible.
- You have not reached the end of your plan’s waiting period and are currently ineligible for coverage.
The doctor diagnoses and provides treatment based on his or her professional judgment and not on the cost of that care. Some employers or insurance plans exclude coverage for necessary treatment as a way to reduce their costs. Your plan may not include this particular treatment or procedure, although your endodontist deemed the treatment necessary.
Your payment portion will vary according to the UCR of your plan, your maximum allowable benefit and other factors. Ultimately, the patient portion is not known until the insurance check has been received by our office.
Your Explanation of Benefits (EOB) is a wealth of information. The EOB identifies the benefits, the amount your insurance carrier is willing to pay and charges that are and are not covered by your plan. The statement includes the following information: UCR, copayment amount/patient portion, remaining benefits, deductible and benefit paid.
The time for a dental insurance carrier to process an insurance claim varies. At least 38 states have enacted laws requiring dental insurance carriers to pay claims within a timely period (ranging generally from 15 to 60 days). If you want to file a complaint about a delayed payment, contact the insurance commissioner in your state. They want to know if your insurance company does not pay within the period allowed by your state law.
Most insurances fall in one or more categories, and there may be more options than are described here. We sign contracts with dental insurance carriers and agree to accept or “take” the payment offered by the insurance company as payment in full, even though it may not be the same amount as the office charges for the procedure. In this case the doctor is a Participating Provider in your plan.
In other cases we do not sign contracts with dental insurance carriers but may still accept or “take” insurance company payments. The doctor is not contractually obligated to accept your insurance carrier’s payment as full compensation and is not a Participating Provider. In this instance, you may be responsible for a payment portion over and above the percentage provided by your insurance company.
In some intances the doctor is not a Participating Provider and does not accept payments directly from your insurance carrier. In this case, the office will ask that you be responsible for the entire fee but will assist you in filing your claim to receive insurance benefits directly from your insurance carrier.
Our office will do our best to answer all of your insurance questions. Please keep in mind that there are many insurance plans available and that your employer chooses your plan and your benefits. If you believe your benefits are inadequate, you may want to discuss the matter with your plan administrator and explore appropriate alternatives.