Insurance Information

At Dentistry at Pelham Pointe, we will you to maximize your insurance reimbursement for covered procedures.  

We are delighted to file your primary insurance once coverage has been established.  However, dental benefits are your responsibility.  We will try to help you calculate your benefit in dollars, with any co-payment and deductible due at the time of service.  Since this is an estimate, even with a pre-determination, there can be no guarantee of what your insurance company will pay.  This may result in a credit or balance due.  Credits may be applied to future treatment or a refund may be requested.  If there is a balance due, you will receive a statement.  

If your insurance has not paid in 30 days, we will re-file your claim.  After 60 days, or if the claim is denied, the full balance becomes your responsibility.  Our insurance coordinator will be glad to answer any questions about your dental coverage, including secondary insurance or health savings accounts.

Prior to your initial visit, please provide your insurance information so that we can expedite reimbursement. For our current patients, if you have had a change in your dental insurance since your last visit, be sure to provide us with updated information.

Frequently Asked Questions…

Why is your name not on my list of Preferred Providers?

We do accept most insurance plans; however, you will not find our name on any PPO list of providers. To date, we have not seen any of these PPO plans that are designed with your health in mind. They are designed to do dentistry as quickly as possible and sell it as cheaply as possible. We pride ourselves on making treatment recommendations based on what we feel is in the best interest of the patient, not based on what an insurance plan will pay.

Why doesn’t my insurance cover all the cost for my dental treatment?

Dental insurance isn’t really insurance (a payment to cover the cost of a loss) at all. It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment. The employer buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost.

But my plan says that my exams and certain procedures are covered at 100%.

That 100% is usually what the insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge. For example, say your charge is $80.00 for an examination, not including xrays. Your carrier may allow $60.00 as the 100% payment for that examination, leaving $20.00 for you to pay.

How does my insurance carrier come up with its allowed payments?

Many carriers refer to their allowed payments as UCR, which stands for usual, customary and reasonable. However, usual, customary and reasonable does not really mean exactly what it seems to mean. UCR is a listing of payments for all covered procedures negotiated by your employer and the insurance company. This listing is related to the cost of the premiums and where you are located in you city and state. Your employer has likely selected and allowed payment or UCR payment that corresponds to the premium cost they desire. UCR payments could be accurately called negotiated payments.

Since most payments are negotiated, does this mean that there is always a balance left for me to pay?

Typically there is always a portion that is not covered by your benefit plan.

I received an Explanation of Benefits from my insurance carrier that says my dental bill exceeded the usual and customary. Does this mean that I am being charged more than I should?

It does not mean that the dentist is charging too much. Remember that what insurance carriers call UCR is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment. It us usually much less than what any dentist in your area might actually charge for a dental procedure.

Why is there an annual maximum on my benefits?

Maximums limit what a carrier has to cover each year. Amazingly, despite the fact that costs have steadily increased, annual maximum levels for dental care have not changed since the 1960’s.

Why does my dental plan only pay toward the least expensive alternative treatment?

To save money.   We may recommend a crown, but your insurance only offers a benefit toward a filling. This does not mean you have to accept the filling. The good news is that some benefit will be paid: the bad news is that more of the fee will be your responsibility. Remember that a dentist’s responsibility is to prescribe what is best for you. The insurance carriers responsibility is to control payments.

Why won’t my insurance pay anything toward some procedures, such as x‐rays, cleanings and gum treatments?

Your plan contract specifies how many of certain types of procedures it will consider annually. It limits the number of xrays, cleanings, etc. covered because these are the types of treatments that many people have frequently.

What should I do if my insurance does not pay for treatment I think should be covered?

Because your insurance coverage is between you, your employer and the insurance carrier, dentists does not have the power to make your plan pay. If your insurance does not pay, you are responsible for the total cost of treatment. Sometimes a plan may pay if patients send in a claim for themselves. The Employee benefits Coordinator at your place of employment may be able to help. Patients may also lodge complaints with the state Insurance Commission.

Why can you only estimate my coverage?

Dentists deal with thousands of plans and hundreds of types of treatments each year. Most carriers refuse to release the details of their plans. They change policies and reimbursements constantly– and without notifying us.

Do you accept Medicare and/or Medicaid?

We are not Medicare or Medicaid providers and are unable to accept payment from these programs.

If you have any problems or questions, please ask our staff. They are well informed and up-to-date. They can be reached by phone at Greenville Office Phone Number 864-271-6705