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Dental plans FAQ

What are the dental benefit plans ("insurances")?

Read this
to understand (or at least to get an idea) on how the dental plans work.



Do you take my dental insurance/plan?

Dental plans vary greatly from a person to a person even at the same place of work. It is no longer enough for a patient to just name a dental plan's company to learn whether a dentist takes it. There are many different plans offered by the same dental plan's company.


We do take most PPO, POS, Discount, Self-Insured, Direct-Reimbursement plans, and some EPO plans.

We take many Medicare Advantage Plans.

We take pediatric Husky Medicaid (age 9-20).

We do take some DHMO/DMO plans. 



Here is current breakdown on different plans:




or read details bellow:


Discount plans:


We participate/in-network with these discount plans: 


Access Dental/AON 
discount plans;

Access Healthplex 
discount plan;

Aegis discount plan of IL and WI;

Alfa Dental ( Blue Expert, Blue Expert+, Beta Care POS, Beta 500, Expert, Expert Preferred discount plans); 

American Dental discount plan;

AON Dental Solutions discount plans;

Beta Health Association Blue Expert, Blue Expert+, Beta Care POS, Beta 500, Expert, Expert Preferred discount plans); 

Careington (Care Platinum POS, Care POS, Care 500, Care HIP, Care ERS, Care ERS 500, LiveWell, MaximumCare) discount plans;

Century Healthcare discount plan;

CHM / Christian HealthCare / Careington LiveWell
discount plan;

Cigna Plus Saving POS/(some discount plans
);

DentalPlans.com
(some discount plans);

DentalSave discount plans;

MaxDental discount plans;

MaximumCare discount plans;

Medi-Share / Careington discount plan;


SavNet / Liberty HealthShare / AON discount plan;

1Dental.com (some discount plans).



With the discount plans, it is important to remember:
1. Treatment with us is provided at a specialist discount level, which fees are different from general dentist fees and discount plan online fees are sample and not actual fees;
2. There is always charges for specialist consultation (or limited exam), radiographs, and necessary test. These fees are in addition to root canal treatment fees;
3. Although these plans provide for discount; they have NO funds on the plan. Therefore entire discounted fee has to be pre-paid or financed* before the treatment is started.



PPO/DPPO/EPO/Indemnity, and other plans:


We participate/in-network with these PPO/DPPO/EPO plans



Aetna (Aetna Dental PPO/PDN  with PPO II/2000 and Extend7)

AlwaysCare

AmeriBen Solutions 

Anthem (Minneapolis address)

AXA / Equitable Dental

Beam Dental

BEST Health Plans

Blue Cross Blue Shield of IL (Blue Care Dental)

Blue Cross Blue Shield of MI (Blue Dental PPO /Standard, Plus Standard, Plus 80/50/50-1000 Voluntary SG, Extra, Pediatric/, EPO Standard)

Blue Cross Blue Shield of MT (Blue Care Dental)

Blue Cross Blue Shield of NM (Blue Care Dental PPO)

Blue Cross Blue Shield of OK (Blue Care Dental Traditional)

Blue Cross Blue Shield of TX (Blue Care Dental)

Blue Cross Blue Shield of Kansas City (not KS, MO, or CA) 

Brokers National

Bright Benefits


Careington and Careington BenefitSolutions (Care Platinum PPO)

Century Healthcare PPO

Chesapeake

Cigna (Total DPPO/DPPO Advantage€ , State of CT Employee Basic & Enhanced plans, and virtually all PPO plans)

Citizens Security Life

Colonial Life /Harrington

ConnectiCare(commercial and pediatric plans administered by
DentaQuest, Careington Demtemax Plus)

Connection Dental Federal/GEHA (High and Standard Options)

CoreSource
(through Cigna and Aetna)

Corporate Benefit Services Inc.

Dearborn National




EncoreDental

Equitable / AXA dental

Free Market Administrators

GEHA/Connection Dental Deferal (High and Standard Options)

Global Dental 

GlobalHealth (Gold 1; Medicare Generations Value, Classic, Select)

Group Administrators
 

Guardian6  (DentalGuard Preferred/Alliance PPO, Select PPO Gold/Silver, Advantage Gold/Silver)

HealthMarkets




Level


Metlife (some PPO)

Merchants Benefit Administrators

Morgan White Dental

Multiflex Dental


Nationwide (Coordinated Benefit PlansHealth Plan Services Employer-provided , and Indivdual Mutiflex /Advantage, Select, SelectPlus/);

Peoples Benefit Life Insurance Company 

Premier Access


Printing Specialties

Renaissance Dental6

Revolv Corvesta

Self Insured Services Co. (SisCo) 

SkyGen


Staff Benefits Management & Administrators;

StarMount

Stonebridge (UHC/DBP)

Superior Dental


Trans America/Encore Dental (some PPO plans)


Unimerica Dental

United Concordia (some PPO)

United Healthcare4 (virtually all PPO/EPO/INO plans, Platinum PPO, Medicare Advantage PPO)

UNUM

Western Teamsters-North West Admin 

Zelis



 

************************************************************
Bellow, there are some important plan specifics:
***********

1. We fully participate/in-network with Total Cigna DPPO and State of CT Employee Basic & Enhanced plans, which means 99.(9)% of the time if the dental PPO plan is paid or administered by Cigna, the discount applies (the remaining 0.(1)% is left for an odd and an extremely rare situation, when a plan does not participate with us).

    Cigna DPPO Business (through a job) plans that we are in-network examples: State of CT Employee Basic & Enhanced, Cigna Employees, UTC Employees^, Town of Enfield Employees, Town of Tolland Employees, Town of Hartford, Hertz, L&M, Genesis, Fedex, Konika, Kindred, Compass, MassMutual, Regional School district 17, Ultra Electron, URS, AT&T SNET, Waterford Hotels, and many many others;

    For Cigna DPPO Advantage plans, DPPO discount applies only if plan specifically states that (based on UCR/Standard PPO and not on maximum allowed fees), percentage of benefit coverage sometimes may differ. If a Cigna DPPO Advantage plan pays based on maximum allowed fees, the plan is out-of-network, and in such case Cigna pays upto their maximum allowed fee, while the patient is responsible for difference between Cigna maximum allowed fee and our regular fees

 ^UTC Employee Cigna plans differ: we are in-network with their PPO plan (discoint applies), while their Indemnity plan that we accept has no network (no discount applies).

      For Cigna DPPO Individual/Personal plans: myCigna Dental Preventive, myCigna Dental 1000, and myCigna Dental 1500 - We are out-of-network on these individual plans, and the patient is responsible for difference between Cigna maximum allowed fee and our regular fees. In addition, Cigna DPPO Individual/Personal plans have 6-month waiting period on radiographs, and 12-month waiting period on root canal treatments during which there are no Cigna payments for such procedures.

     
Estimated patient's portion has to be pre-paid or financed* before the treatment is started.



2. We participate/in-network with Cigna Dental Shared Administration Plus  plans.

    We also accept Cigna Dental Shared Administration (regular) plans (the discount is not guaranteed; when DPPO discount applies, percentage of benefit coverage sometimes may differ).

Estimated patient's portion has to be pre-paid or financed* before the treatment is started.


3. We participate/in-network with Guardian PPO DentalGuard Alliance / DentalGuard Preferred, Select PPO Gold/Silver, Advantage Gold/Dilver plans through Careington network.

For Patients on Guardian plans: diagnostic procedure "Pulp test" (coded D0460) and treatment procedure "Post space" (coded D3950) are NOT covered by Guardian dental plans. On EOB (Explanation Of Benefits), Guardian does state that they are not covered, and also mentions "Considered Charge". However, those amounts are only considered when the procedures are covered. Because they are not covered, the full charges  apply and to be paid by the patient.  Guardian asks to "disregard patient responsibility amount" on EOB due to this issue.

Guardian Select PPO Gold/Silver and Advanatge Gold/Silver have 12-month waiting period on endodontic (root-canal) treatments during which Guardian does not pay (you may still get contracted fee).

Estimated patient's portion has to be pre-paid or financed* before the treatment is started.


4. United Dental Primary/Essential/Premier Preferred and Elite plans have 12-month waiting period on endodontic (root-canal) treatments during which United does not pay (you may still get contracted fee). 

    United Dental Primary/Essential (non-Preferred) plans do NOT cover endodontic (root-canal) treatments at all, thus United does not pay for them and contracted fees do not apply.

    
5. We accept insurance assignment (as out-of-network) on most PPO/DPPO plans (but no EPO) if they agree to it and provide us with estimated amounts.

Estimated patient's portion has to be pre-paid or financed* before the treatment is started.
/The only exception are (self-funded only) Delta Dental plans, for which the entire cost of the treatment has to be pre-paid or financed* before the treatment is started, and we will arrange for reimbursement to be sent by the plan to the patient rather than the office./

6. For Patients on Guardian and Renaissance plans, we only do basic root canals treatments (no calcified cases and no re-treatments).

7. In regards to Aetna plans, we are in-network with AetnaDental PPO/PDN with PPO II and Extend℠. If the plan does not contain the word "Extend", we are out-of-network.




Here are some companies, which PPO/DPPO/EPO plans we accept overall

(in-network plans shown in bold) 


Aetna (Aetna Dental PPO/PDN  with PPO II/2000 and Extend)

Aflac Dental;

Altus Dental;

Alwayscare;

AmeriBen Solutions;

American Dental;

American General;

Ameritas;

Anthem Blue Cross & Blue Shield (example: PPO, Complete, Prime, Grid, Grid+) (some in network: Minneapolis address )

Anthem BCBS of  TX, IL, NM, OK, MT, MI, and Kansas City (not KS, MO, or CA) ;

AXA / Equitable dental;

Axis dental (My Ternian/Ace American Dental);

Beam Dental;

BEST Health Plans

Blue Cross Blue Shield of IL (Blue Care Dental);

Blue Cross Blue Shield of MA

Blue Cross Blue Shield of MI (Blue Dental PPO /Standard, Plus Standard, Plus 80/50/50-1000 Voluntary SG, Extra, Pediatric/, EPO Standard);

Blue Cross Blue Shield of MT (Blue Care Dental);

Blue Cross Blue Shield of NM (Blue Care Dental PPO);

Blue Cross Blue Shield of OK (Blue Care Dental Traditional);

Blue Cross Blue Shield of TX (Blue Care Dental);

Blue Cross Blue Shield of Kansas City (not KS, MO, or CA);

Blue Cross & Blue Shield Premera;

Bright Benefits;

Brokers National;

Careington  and Careington BenefitSolutions (Care Platinum PPO, Care PPO, HIP Prime); 

Century Healthcare PPO;

Chesapeake;

Cigna (example: Total Cigna DPPO, some DPPO Advantage, Cigna State of CT Employees Basic and Enhanced, Cigna Employees, UTC Employees (non-indemnity and indemnity), Town of Enfield Employees, Town of Tolland Employees, Town of Hartford, Hertz, L&M, Genesis, Fedex, Konika, Kindred, Compass, MassMutual, Regional School district 17, UCONN Health Partenership, Ultra Electron, URS, AT&T SNET, Waterford Hotels, myCigna Dental Preventive, myCigna Dental 1000, myCigna Dental 1500, Cigna Dental Shared Administration, Cigna Dental Shared Administration Plus, some CoreSource, and many more);

Citizens Security Life;

Colonial Life/Harrington;

ConnectiCare/Benecare (Value, Plus, Premium, MedicareVIP); 

ConnectiCare (commercial and pediatric plans administered by DentaQuest,Careington, and Dentemax Plus /ex. Connecticare Solo Adult PPO/, Medicare Advantage administered by DenteMax);

Connection Dental Federal/GEHA (High and Standard Options);

Connection Dental;

Core Dental (Platinum, Gold, Silver, Value);

Core Five Solutions;

CoreSource (through partnership with Cigna-PPO, Aetna, Cigna Dental Shared, or PHCS/MultiPlan);

Corporate Benefit Services Inc. ;

Cypress Dental Administrators;

Dearborn National;

Delta Dental (AK, CA, CT, IL, GA, NJ, NY, KY, MA, MI, MN, MO, PA, RI, VA, WA, WI, NorthEast (ME, NH, VT), AARP, Veterans Affairs, National, PPO/Premier);

Delta Health Systems;

Dental Select;

DentaQuest (ConnectiCare commercial and other plans);

DenteMax (commercial and Medicare Advantage);

DHA;

Diversified Administration Corporation (DAC);

DNOA

Emblem Health/GHI;

EMI Health

Employee Painters Trust Health and Welfare;

Encore Dental;

Entrust;

Equitable / AXA dental;

Free Market Administrators;

GEHA/Connection Dental Federal (High and Standard Options);

Global Dental;

GlobalHealth (Gold 1; Medicare Generations Value, Classic, Select)

Group Administrators;

Guardian
(DentalGuard Preferred/Alliance, Select PPO Gold/Silver, Advantage Gold/Silver) - diagnostic, basic (non-re-treatment, non-complicated) root canal treatments, and post space preparations only;

HealthMarkets;

HealthNet (in-network with one based in AZ, WA, CA, OR)

HealthPlex;

HealthScope Benefits;

Humana PPO (we are in-network excluding AL, AR, CT, GA, FL, & LA) ;

IHC (PPO and Indemnity plans);

I.U.B.A.C. Local 1;

Keiser;

Key Benefit Administrator

Landmark Open Access & PPO;

Level;

Liberty Dental;

LifeMap;

Lincoln Financial;

Lincoln National Life;

Local 1 HealthFund;

Medico;

MetLife (some PPO, Take-A-Long Dental, Tri-Care) - most out of network;

Merchants Benefit Administrators;

Morgan White Dental

Mutual of Omaha;

Nationwide (Coordinated Benefit PlansHealth Plan Services Employer-provided , and Indivdual Mutiflex /Advantage, Select, SelectPlus/);

National General Accident and Health PPO and IP;

National Elevator Industries plans / NEIHBP;

NorthEast Delta Dental (ME, NH, VT);

Peoples Benefit Life Insurance Company 

Pequot (PPO and Plus);

Physicians Mutual Dental

Premera BlueCross;

Premier Access

Premier Dental DHA;

Printing Specialties

Principal;

Renaissance Dental

Revolv Corvesta

Secure Dental One;

Security Life (Plan V/Indemnity and some PPO plans, Meritain);

Self Insured Services Co. (SisCo);

SkyGen;

Solstice;

Spirit (Spirit Dental Indemnity, Spirit Choice, Spirit Choice 1200, some Spirit Network 1200);

Staff Benefits Management & Adminstrators;

Standard;

StarMount;

Stonebridge (UHC/DBP);

Sun Life Dental /Assurant Dental;

Superior Dental;

SureBridge;

S&S (Stop&Shop);

Teamsters (Local 1035, General 493, and other);

Terninan;

Time Insurance;

Trans America/Encore Dental

UMR;

Unimerica Dental

United Concordia;

United Healthcare (PPO, PPO 20, PPO 30, and EPO/including Saudi Arabia EPO/INO, Platinum, Medicare Advantage);

United Healthcare International/Global (including Saudi Arabia EPO);

UNUM;

Wellcare (through Healthplex);

Western Teamsters-North West Admin 

Zelis

and many other PPO plans.

In case of being out-of-network for some plans, we do take/accept above PPO plans through assignment of benefits if the plans allow (not on EPOs). 

By taking/accepting a dental plan, we mean that we may be able to accept payments from the dental plan for their portion, while a patient only pays his/her co-insurance (deductible, co-pay, etc.). This applies to both in-network and out-of-network plans. There has to be enough money on the plan to pay at least $200 toward exam/x-rays and at least $500 toward root canal treatments, the dental plan informs us on how much they will pay us and agree to send payments to us. The patient is responsible for any funds unpaid by the dental plan.

Estimated patient's portion has to be pre-paid or financed* before the treatment is started.




Medicare and Medicaid:


We
are in-network with United Healthcare Medicare Advantage

We are in-network with GlobalHealth Medicare Advantage

We are in-network with Humana PPO Medicare (excluding AL, AR, CT, GA, FL, LA, which we are out-of-network)

We accept ConnectiCare Medicare VIP (as out-of network). 


We are in-network on limited bases with Husky A, B, C, D: patients of age 9-20 years only for basic (non-re-treatment, non-complicated) root canal treatments only#. We also see Husky patients age 21+ for non-covered re-treatment procedures only# (patients age 21+ on Husky plan have to pay for these non-covered procedures).           
#If Nitrous Oxide is needed, it is important to know that it is NOT covered by Husky for most patients age 9+, may need to be per-authorized for decline, and has to be paid by the patient before start of the procedure with no refund if procedure cannot be performed.

Estimated patient's portion (including Husky B co-pay) has to be pre-paid or financed* before the treatment is started.




Self-funded and Direct Reimbursement (SF/DR) plans:


We participate/in-network
with Cigna Dental Shared Administration Plus SF plans.

We accept (as out-of network) Cigna Dental Shared Administration (regular) SF plans (the discount is not guaranteed; when the discount applies, percentage of benefit coverage sometimes may differ).

We accept insurance assignment on most other SF/DR plans if they agree to it and provide us with estimated amounts.
/The only exception is (self-funded only) Delta Dental-administered plans, for which the entire cost of the treatment has to be pre-paid or financed* before the treatment is started, and the reimbursement will be sent by the plan to the patient rather than the office
./

Estimated patient's portion has to be pre-paid or financed* before the treatment is started.


Direct Reimbursement plans :

We accept the following DR plans:


Aflac Dental;

Physicians Mutual Dental;


With direct reimbursement (DR) plans , it is important to remember:
1. The DR plans simply pay a portion of treatment (the amount of benefit is not a fee for a procedure);
2. These DR plans have 6-12 month waiting period for endodontic procedures (no coverage during 6-12 month after signing up for DR plans).



DHMO/DMO/Capitation plans:


We are out-of-network on DHMO/DMO/capitation programs. 

We can still use these plans if they have out-of-network benefits (example some Aetna DMO from Bank of America and Connecticare Medicare Passage HMO Plans).

"Obamacare" dental plans:



We accept  (as out-of network) Obamacare Dental Plans:

Access Health CT plans (Platinum, Gold, Silver, and Bronze through ConnectiCare/Benecare, Anthem BlueCross BlueShield, and HCT/HealthCT/Delta).

Keep in mind that Obamacare Dental Plans plans have very high deductibles (in thousands of dollars), which must be met before they pay for any root canal/endodontic treatments, and may require prior authorization.

Estimated patient's portion has to be pre-paid or financed* before the treatment is started.




We utilize fast e-claim service to ensure accurateness. So, bring your benefit card and government-issued ID, and we will be happy to help you to utilize the program. Please read on what payment options we offer.

Please also keep in mind that dental plan negotiated fees and rules often differ from office to office and may be based on zip codes; most plans pay differently to specialists.




What are common dental plan limitations?

Although dental plans vary, bellow there is information on certain common situations with particular dental plans:

1. Many plans do not cover a pulp test (D0460).

2. Few plans cover a post space creation(D3950) (Cigna PPO Basic State of CT Employee, Husky under 21, few other).

3. Some dental plans do not pay for a specialist consultation (D9310) and when paid - not with treatment (ex. Guardian); most will not pay for a limited exam (D0140) if it was charged in last six months at any office. Most non-CT Anthem Blue Cross & Blue Shield (BC&BS) and Blue Cross & Blue Shield Premera
do NOT pay for either D9310 or D0140. Guardian PPO does NOT cover exams (either consult  - D9310 or limited - D0140) or x-rays on the same day of treatment, while patient is still responsible for fees on those procedures.

4. Plan's statement that it covers root canal procedures at 100% is usually inaccurate or irrelevant. It is because most of such plans have very low annual limit, which is usually bellow the total fees for the procedures Exception are some Cigna PPO (Towns of Tolland and Enfiled have paid 100% in the past).

5. There are no dental plans, which cover everything. Dental plans do not keep up with the lasted in dentistry and all dental plans exclude most cosmetic procedures. Do not confuse "no maximum for the year" or "no cost share" with "everything covered". Read this notice from state of Connecticut in regards to non-covered services.

6. If plan's annual limit is less than $1750, it is more likely that there will be less coverage. Most plans have a limit of only $1000/year and few as low as $500/year. On the other hand, plans with high maximum does not mean they pay 100% of treatment (we have seen $15000/year plan, which paid only $400 toward treatment of $1500).

7. "Surgical procedure for isolation of tooth with rubber dam" - D3910 is rarely covered and not on the same day as a root canal treatment. Some plan argue that it is part of a root canal procedure, when, according to American Dental Association (who owns the copyright on codes), it is not.

8. For some dental plans, it is difficult to obtain specific and detailed information on benefits (sometime it is due to them being closed outside of day-time weekday hours (example: ConnectiCare, Blue Cross Blue Shield, DAC, Delta Dental), or plain refusal to disclose fees (example: most Delta plans, all Blue Cross Blue Shield Premera, some Blue Cross Blue Shield of Connecticut plans, all Blue Cross Blue Shield of Connecticut of Massachusetts). Therefore, full pre-payment or monthly payments* may be required to render services with certain plans.

9. Whenever there is a crown in process on any teeth, some dental plans (example: Guardian PPO) may ask us to return funds for endodontic procedure after a crown completion charge is processed because they pay based on the date of the procedure start not completion. Therefore, full pre-payment or monthly payments* may be required to render endodontic services in such cases.

10. Some dental plans (example: Husky for 20+ years old) do not cover root canal procedures with certain teeth missing. Full fee pre-payment or monthly payments* may be required to render endodontic services in such cases and we may have to way for dental plans to process some paperwork before treatment.
 

11. There are dental plans, which only cover non-restorative procedures (exams, cleaning), thus there is no coverage for root canal treatment (example: myCigna Preventive, Wellpoint, Secure Dental BasicOne, Assurant Supplemental Basic and Intermediate, BCBS [Obamacare] Adult Plans Prime A and B, ConnectiCare Solo, United Primary/Essential (non-Preferred), other "wellness", "basic", and similar plans). Contracted fees do not play in such cases.

12. There are plans, which require 6-24+ months of waiting period before procedure coverage (example: Aflac, Secure Dental ClassicOne, BCBS [Obamacare] Adult Plans, myCigna, Guardian Select and Advantage, United Preferred/Premire (incl Elite)) or pay half of regular coverage during the waiting period (example: Assurant Supplemental Dental). Therefore, full pre-payment or monthly payments* may be required to render endodontic services in such cases.

13. Some plans pay less in first 1-3 years (example: Landmark Dental, some DHA, Spirit Dental, Secure Dental One, Assurant Supplemental Dental, Aflac, United Premier (incl.Eite). Thus you co-pay may be higher.

14. For most re-treatment and surgical procedures, there is not enough coverage or/and annual funds for dental plan to pay.

15. Some dental plans do NOT pay for re-treatment procedures the same year as regular root canal treatment on the same tooth; some plans require 2+ years of waiting (example: Cigna PPO 50, Delta Dental). Some plans do not cover re-treatments at all (ex: Husky for 21+ years old), and many do not cover/pay post/obstruction removal (ex: ConnectiCare, Husky). Therefore, full pre-payment or monthly payments* may be required to render endodontic services in such cases.

16. Rare, but some plans will only reimburse to the patient and not to us (ex: some self-funded Delta Dental PPO, some ConnectiCare Value PPO,  some self-funded employer reimbursement plans, BC&BS Federal for postal employees). Full fee pre-payment or monthly payments* is required to render endodontic services in such cases.

17. We do NOT take DMO/DHMO/Capitaion plans and non-United EPO/INO plans, and they do not reimburse us or the patient. Full fee pre-payment or monthly payments* is required to render endodontic services in such cases. 

18. Discount plans / POS plans are reduced fee plans (ex. Careington Care500, Access, Cigna Plus Savings, etc.), and although we take many of them, there is no reimbursement by these plans. Therefore pre-payment or monthly payments* is required to render endodontic services under these plans. These plans usually provide for contracted percentage adjustment to our regular fees (not general dentist fees as usually listed online) rather than specific fees.

19. Most dental plans' estimates obtained within short-time after other treatments/exams are not accurate. It is because most plans take time to process claims and not always provide information on claims in progress. Time varies (ex: Guardian, MetLife, Aetna  - 1-2 weeks, Cigna, Blue Cross of MA  - 1+ months) and based on when other dentists file claims. To add to insult, some plans pay based on date of a service not on date of service's claim submission (ex. Guardian PPO), so it is possible to be additionally charged much later unless you pre-pay or fully finance with monthly payments*.

20. Remember dentist periodic "cleaning"/check up is not free, "covered", or "included", it is charged against a dental plan. In addition, "shopping around" will only result in using precious frequency-limited limited exams (D0140) and specialist consultations (D9310) against annual funds limit with sure way to get unexpected dreaded high bills.

21. Some companies conduct updates to their eligibility verification system (example: Husky 21+), which may prevent us from seeing patients with those plans during such downtime.
 
22. Many plans do not cover complex trauma treatment such as teeth splinting, reimplantation of avulsed teeth, etc. Some plans do not cover endodontic treatment at all if it is trauma-related. Full fee pre-payment or monthly payments* is required to render endodontic services in such cases. 

23. Most dental plans do not cover regenerative therapy such as apexogenesis and have incomplete coverage of treatment for teeth with open apices such as apexification. Full fee pre-payment or monthly payments* is required to render endodontic services in such cases.

24. Some dental plans share high deductibles with medical plans and until the deductibles are fully met, no dental benefits are paid. (Example is new Obamacare dental plans for children in Connecticut through Access Health CT, which have deductibles ranging from $1000-8000/person.) Full fee pre-payment or monthly payments* is required to render endodontic services in all cases when medical deductibles are not yet met.

25. We may be unable to perform non-covered services with some plans due to plan restrictions, limitations, or simply due to too much hassle with the plan. (Ex: 1) For all Husky plans, we will perform only covered services or do not do treatment at all except for root canal re-treatments on adults, root canal treatments on molar/pre-molars on adults with missing teeth in the area of treatment, or/and desensitization. Full fee pre-payment or monthly payments* for these non-covered services are required and, in case of missing teeth clause, may have to wait for treatment until necessary paperwork is processed. 2) For all ConnectiCare, we will generally perform only covered services) Deductibles, co-apys, co-insurance fees, and other charges for covered services due to frequency limitations/plan year maximums still apply. 3) For Cigna, we may perform some non-retreatment root canal procedures in single visit due to program limitation. 4) For Guardian, we generally perform only basic root canal treatments (no re-treatments, no severely calcified canals, no post removal)) and only those we can do in single visit due to program limitations.

26. Some dental plans require prior authorization for treatments to be paid (ex. some Obamacare plans).
Full fee pre-payment or monthly payments* is required to render endodontic services if patient does not want to wait.

27. Rarely, but few plans (usually Blue Cross Blue Shield and Guardian) do not pay even for diagnostic radiographs on the same day of service.


28. Few plans will pay for re-cementation of a crown by endodontist (Cigna PPO Town of Tolland - only known).

29. Some rare dental plans will only pay out-of-network with special permission and only by reimbursement to the patient  (example: BC&BS Federal Postal Employee program)

30. Some new dental plans have deductibles that apply to basic radiographs, after which they pay percentage of remaining amount even for in-networks plans resulting in no or little payment for such codes.

31. Some plans do not belong to any network (although they may carry a name of major plan) (ex: Cigna Indemnity plan for UTC employees). With these plans, contracted fees do not apply  - the plan will pay upto plan maximum and patient responsible for the rest.


We do utilize fast e-claim service to ensure speediness of reimbursements. Most of claims filed same day of completion of all procedures with us. Please explore our monthly payment programs and other ways to pay* for convenient  budget-friendly financing and piece of mind.


My plan is out of network with your office, do I have to pay all upfront, do I do my paperwork with "insurance"?

It all depends on the plan and not whether we are in- or out-of-network.
See details bellow:

We are out-of-network for all DHMO/DMO/Capitation and out-of-network EPO/INO programs. Due to their restrictions, there is no funds when going out-of-network, full fee pre-payment or monthly payments* is required to render endodontic services on most DHMO/DMO plans and all out-of-network EPO/INO plans.

We are in-network with some POS plans such as Careington POS (Care Platinum, CarePOS, Care 500, and HIP Preventive/VIP), Access/AON, Cigna Plus Savings(POS), Healthplex, DentaplPlan.com
. However, these plans are discount plans and there are no money on them, thus, discounted fees must be pre-paid or monthly payments* are required to render endodontic services.

For PPO plans, when we are out-of--network,
we can still generally take/accept most other of them through assignment of benefits if the plans agree to it (most do). By taking/accepting a PPO dental plan, we mean that we may be able to accept payments from the dental plan for their portion, while a patient only pays his/her co-insurance (deductible, co-pay, etc.). For patient convenience, we process all necessary paperwork regardless whether we are in- or our-of-network.

There has to be enough money on the plan to pay at least $300 toward exam/x-rays and at least $500 toward root canal treatments, the dental plan informs us on how much they will pay us and agree to send payments to us; this applies to both in-network and out-of-network plans. The patient is responsible for any funds unpaid by the dental plan. Another word: Just because we are in-network does not mean that we can take patient's plan, and just because we are out-of-network does not mean that patient has to pay all upfront. 

In any case, if there is any portion that the patient has to pay may be paid monthly* if approved.



My plan pay is based on UCR/ prevailing rate fees, but my friend' plan pay is based on fixed fees, but we have the same dental plan company. What is the difference?

UCR/prevailing rate fee plans pay based on average rates for the geographic areas and pay up to dentist contracted fee. These plans may be more expensive to buy for your employer, but have better payout, so there is less out-of-pocket portion when you go to a dentist. (Example: composite fee UCR rate is $200, dentist contracted fee is $200, patient pay is $0.)

Fixed fee plans, as the name states, pay fixed amount to the dentist per procedure. These amounts pay generally much lower than dentist charged fee, but do not get excited because you will have to pay the difference between fixed fee and contracted fee even if you go to contracted dentist. The plans are less expensive to buy, but worse at payout, so there is always and larger out-of-pocket portion when you go to a dentist. (Example: composite fee fixed rate is $100, dentist contracted fee is $200, patient pay is $100.)

It is important to understand that going to in-network doctor with fixed fee plan may still result in out-of-pocket payments even on procedures "covered at 100%" because the fixed fee plans pay "covered 100%" only up to maximum fee, then patient pays the rest up to dentist' contracted fee. Keep also in mind that one dentist contracted fee may not necessary be less than a fee charged for the same procedure by non-contracted (out-of-network) dentist. We know that it is confusing, but that how it is.


How much my insurance covers (what percent of cost)? My plan says that it covers 80%, but when it pays, it look like it is 50% or less. Why is that?

Unlike dental check-ups, preventive procedures, and small restorations, dental benefit programs are extremely inadequate in coverage of more complex cases such as bridges, root canal treatments, periodontal surgeries, implants, and others.

The biggest problem is annual limits on dental "insurances", which are very low and often bellow the cost of complex procedures, so the percentage of coverage (80%, 70%, etc,) does not make sense.It is because there are simply not enough money on plans to cover even the stated percentage of these procedures. Oh, and do not forget about such limitations like waiting (aka - no-coverage) periods, reductions in coverage percentage (often if you have not seen your general dentist for awhile), deductibles, missing tooth clause, re-treatment waiting periods, and other gimmicks. Therefore, the plans often pay about 40-50% of billed costs.

Read more about "dental insurances" here, e
xplore what payment options we offer.


I have two "insurances", do I have to pay anything?

Usually yes. Having secondary insurance may result in more funds payable, but not always,and sometime less. Each situation is different.

First of all, primary simply means that they have to pay or deny first before second pays or denies; it has nothing to do with how much they pay and we have yet to see both plans pay up to 100% of our fees, have unlimited funding, cover all dental codes, and require no radiographs and narratives.

Second, if any the plans are HMO/DHMO/EPO/Capitation, require radiographs, or do not have out-of-network benefits (example Delta Self-Funded), we cannot use them ("unusable plans"). If any of unusable plans are primary and in some cases if any of them are unusable plans, the entire cost has to be pre-paid or financed* before the start of the procedures, we will then submit claims to both plans payable directly to the subscriber.

Finally, if we accept both of the plans and agree to wait for their share of payments, the out-of-pocket portion is calculated based on lower-paying plan regardless whether it is primary or secondary.

Read more about "dental insurances" here, e
xplore what payment options we offer.



I want/need to use my spouse plan because mine has maxed out. Can I do it?

No problem, and we still need to bill your primary plan to receive $0 payment EOB (explanation-of-benefits) to get paid by your secondary, so please provide us with insurance info on both plans.



Why my consult/exam with specialist may not be covered?

Most dental plans have some coverage for exams, but there is often a limit on number of them covered per time period (not per dentist), type of exams covered, and when they are covered.

Let's discuss number of exams covered. When a patient comes to a specialist from his/her general dentist, the patient usually has at least one exam already performed by the general dentist. If a dental plan covers one exam every 6 months, and the patient comes straight from the general dentist, the dental plan does not cover the exam because the patient has exceeded the maximum of paid exams (one in 6 months regardless of who performs the exam).

In regards to the type of exams. Some dental plans only pay for a comprehensive exam (code D0150) done by a general dentist (and often only once every 12 or 60 months), and not for a limited exam (D0140), extensive exam (D0160), or a specialist consultation (D9310), thus the patient has to pay every time they have exam at a specialist office.

Finally, about when exams are covered: some dental plans, despite American Dental Association code description, refuse to pay for exams done by specialists on the same day of treatment (example Guardian PPO). However, since most dental plans have inadequate annual maximum to cover single root canal treatment let alone combined with exam, the issue is irrelevant. 


Read more about "dental insurances" here, e
xplore what payment options we offer.


My insurance company wants me to go to an in-network endodontist, but my dentist wants
to me to go to the out-of-network one. What should I do?

Listen to your dentist because he/she recommends based on your needs and qualification of the endodontist, while your dental insurance cares about their bottom line. The insurance often pay less in claims to the in-network doctor, then to out-of-network doctor.

Important, it is not always true that in-network prices are lower than out-of-network. Most of network doctors are forced to submit regular (never-to-be charged) fees to insurance companies to get fees closer to usual-customary-and-reasonable (UCR) ones. They also do it to compensate for forced-to-be-done-for-free procedures the insurance wrongfully considers part of another treatment done same day (example: tests). The doctors join networks to get publicity and patients, and, although, they understand that fees will be reduced, they cannot have them reduced too low and loose money (anything more than 15-20% off pre-paid or 5-10% financed should raise the alarm). (There are few doctors who will lower the quality of work or do more than needed to get you super-low prices per procedure, but then do not complain when treatment fails). Out-of-network doctors simply charge usual-customary-and-reasonable (UCR) (aka. patient-vetted) fees.

Therefore, if you are out of benefits, a procedure is not covered, or let's say you need a root canal, while you had a root canal on same or different tooth in last 2 years, you most likely will pay much higher fees (or get that huge unexpected-at-worst-time bill) at the in-network endodontist because of non-payment by the insurance. In addition, the out-of-pocket portion (the maximum in-network dentist can collect upfront) may be too high for the patient to pay upfront, but too low to qualify for best monthly payment plans. The patient can finance the whole procedure at out-of-network doctor or perhaps even get a better price when pre-paid. Remember, most of out-of-network doctors will still bill your insurance if you ask.

Read here more on this topic at another doctor website.

Checkout what payment options we offer.

The point - choose your doctor based on quality, reputation, and care, - not based on network participation. Remember, it is your health that is at stake.


I am signing up for ObamaCare / Access Health CT and they come with dental plans. Do these plan differ from "regular" dental plans?

There is no such thing as a "regular dental plan" All dental plans differ in coverage and no plan covers everything.

In regards to Access Health CT plans (based on information provided by them and elsewhere):

1. ObamaCare Dental plans as part of medical plans cover patients up to age 18 only ("ObamaCare pediatric dental plans"). Stand alone plans (through Anthem BCBS Prime Plans A-C) cover any age.

2. "ObamaCare pediatric dental plans" have no annual maximum and waiting periods. Stand alone ones have limit of $500-1250/year/person, and some cover only cleanings and check up, and not root canal treatments.

3. All "ObamaCare pediatric dental plans" are subject to BIG medical (yes, medical) deductible. It ranges from about $1,000-$8,000/year/person. It means that there will be no root canal procedures paid until after the deductible is met, which is a tall order unless the child has been hospitalized same year for extended period of time. Keep in mind that the deductible is on a top of any co-pays paid.

4. All "ObamaCare pediatric dental plans" have frequency limitations on number of exams and x-rays. It means that even it says, "no member cost", there may be a charge for it. (Example: according to BC/BS "pediatric plan" - "Any type of evaluation (checkup or exam) is covered 1 time per 6-month period". It means that when a patient comes after a general dentist exam to a specialist, the patient will have to pay for a specialist exam due to 1 exam in 6 month policy coverage.)

5. Some of the procedures of "ObamaCare pediatric dental plans" require prior authorization for to be paid. Therefore, full pre-payment or monthly payments* may be required to render endodontic services if a patient does not want to wait.


6. On positive side, with "ObamaCare pediatric dental plans", patients can go to any specialist whether in- or out-of-network. It is a good thing because due to very high deductibles, the patients, in most cases,  will have to pay for all endodontic / root canal services with these plans in full anyway. In addition, currently, there is limited number of in-network specialist with these plans, so out-of-network coverage make it easier to get treatment. By the way, do not assume that you save on cost when treated in-network due to the fact that in-network doctors have to charge fees for all procedures performed regardless whether the dental plan pays them or not (and these plans often will not), while out-of-network doctors may give a discount when pre-paid and still send claims to these plans to try to get some money back to the patients.


Read more about "dental insurances" here, e
xplore what payment options we offer.


How do I pay for co-pay and treatment?

If a patient has a dental plan, and we are able to estimate out-of-pocket portion, the patient usually pays that portion (any unpaid by the dental plan balance is responsibility of the patient/legal guardian/guarantor -see above information on dental plans).

For those
without dental plans and for out-of-pocket portion for those with dental plans, payment is made before treatment start with cash, check, card, money order, PayPal, CareCredit Pay, or Bitcoin. We also offer third-party financing*. If we do bill, there are additional billing charges ($15 per each e-statement / paper statement) + interest.

Checkout what payment options we offer. 

There are also several peer-to-peer lending programs available on-line to obtain loan to pay for treatment.
Check out one of them -  Prosper, where you can obtain a loan for dental work.
 



Can I postpone root canal treatment until new "insurance" year to have more funds?

It depends, if it is a few days away, may be yes (assuming you are not in pain and the tooth does not break before that day). Otherwise, it is a really bad idea because untreated problem will only get worth: decay gets larger, swelling/infection may occur, and the tooth can break, which will ultimately result in higher cost of more complex treatment (that is assuming that the tooth is still restorable), which often are not covered by "insurance".

 

Call for an appointment

860-253-2573

Endodontic Specialists


 1050 Sullivan Ave, Suite B2   
South Windsor, CT, 06074

***and***

14 East Hampton Rd
     Marlborough, CT 06447
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