Dental Overview

It is well accepted in dentistry, prevention and early intervention is the most successful approach to good oral health. It is also the most cost effective. When both the patient and the dentist has incentives to prevent disease and maintain oral health, then fewer procedures are necessary. The patient is healthier, happier and has less out-of-pocket cost. The provider is more successful, both professionally and financially.

Keeping in mind that Managed Care Dentistry emphasizes Preventive Treatment. All examinations, diagnostic treatment and routine cleanings (every six months) are covered at 100%. Overall dental health is maintained thus preventing more serious and costly procedures down the road.

Dental services are typically organized into one of five categories:

  1. Basic (examinations, x-rays, scaling and polishing, fillings, etc.)
  2. Endodontics (root canal, pulpotomy, pulpectomy, etc.)
  3. Periodontics (root planing, treatment of gum disease, etc.)
  4. Major Restorative (crowns, bridgework, inlays, dentures, etc.)
  5. Orthodontics (the diagnosis and treatment of misaligned teeth)

Exclusions to this coverage include:

  • Temporomandibular Joint (TMJ) Treatment;
  • Cosmetic Services; and

Dental Health Maintenace Organization (DHMO) stresses the importance of regular visits to the dentist. It covers diagnostic and preventative services, such as routine checkups, cleanings and x-rays, at 100%. These are often delayed because of anticipated out-of-pocket expenses, yet they can minimize or eliminate the need for more extensive – and expensive – treatment later. Other services, such as fillings, crowns, extractions, etc., may require a copayment from the member. In a DHMO, members select a primary dental office from a contracted and credentialed network of providers. The primary dental office, or PDO, handles all of their dental care needs, including referrals to specialists when needed. PDOs see their patients regularly and establish on-going relationships.

UCR rates refer to medical research which has determined the fair and reasonable charges for various medical procedures and treatments as well as fee for service charges based on the region of the country in which those services are provided. UCR rates refer to medical research which has determined the fair and reasonable charges for various medical procedures and treatments as well as fee for service charges based on the region of the country in which those services are provided. UCR rates refer to medical research which has determined the fair and reasonable charges for various medical procedures and treatments as well as fee for service charges based on the region of the country in which those services are provided.

A traditional, fee-for-service dental plan that offers comprehensive benefits and the freedom to select any dentist. Payment is based upon program coinsurance levels and schedule of maximum allowances.

Typically: 100%-Preventive services; 80%-basic services; 50% major services;

$50 deductible; $1000 maximum.UCR rates refer to medical research which has determined the fair and reasonable charges for various medical procedures and treatments as well as fee for service charges based on the region of the country in which those services are provided.

In a dual choice or point of service programs, plan members are offered the option of:

  • a traditional fee-for-service plan with reimbursement of eligible procedures made through the dentist of their choice; or
  • the Managed Care plan providing access to a broader range of services provided by a network dentist.

In a “point of service” program, plan members:

  • can attend a non-network dentist and pay a co-pay; or
  • can attend a network dentist and incur less of out-of-pocket expenses.