Our office J. Rivas Dental welcome non-insured patients and insured patient. Most PPO dental insurance plans are accepted. Our office does not participate with HMO, co-payment plans, some individual dental plans, some government funded plans, and some PPO dental insurances. You may contact our office front desk staff to verify coverage before your appointments. If you have a participating dental insurance plan and provide us with your policy information, we will verify your eligibility and coverage, as well as file your dental insurance claims for you.
It is crucial you understand that you are the solo financially liable for payment of service rendered in our office. Dental insurance coverage, co-pays, deductibles and dental procedures frequency, are determined by the dental insurance plan you selected and not for us. Please check with your dental insurance company to understand your coverage and your responsibilities. Co-pays, and deductibles are expected to be collected at each visit. Please be sure to bring your insurance card to your appointment, if any. You are responsible to advise us of any changes to your insurance information or mailing address. If we have not proved of active coverage of your dental insurance at the time of your visit, you may ask to pay for any services rendered in our office.
In the spirit of transparency, and to meet current federal regulations, we provide a document that lists gross charges for specific procedures and/or services. Our price estimator system provides an instant good faith estimate that is applicable at the time of your request. The actual total out-of-pocket costs may be different than the amount shown in the estimate. These estimates may have some changes after your dental insurance has paid its portion. Your final costs may vary from this estimate for many reasons, including but not limited to percentages as described in the plan you chose, but also it is adhered to some other insurance non-covered services, deductibles, clauses and/or regulations of dental services, ex. downgrade a particular service like fillings, crowns, bridges, among others. Remember, you will be liable for any unpaid service rendered in our office whether you have insurance or not. Any unpaid balance will be transfer to a collection agency after 90 days from the day of service. We encourage patients to fully read your dental insurance benefit book to be familiar with it before buying it.
Once your insurance company has paid, you will receive a bill that will reflect any remaining deductible, co-payment or patient responsibilities. We accept the following forms of payment:
Pre-Approval. What you need to know about Predetermination. Pre-Estimate of Benefits. Preauthorization?
These terms are very confusing to patients—even to staff! So, what do these terms mean? It is a process entailing a lot of work that results in no firm answer regarding payment. Again, a predetermination not a guarantee of payment from your insurance company, it is simply an of the patient’s benefits. However, it can only be accurate if the deductibles, maximums, and waiting periods are calculated in. Many times, they are not!
One is example is a patient who had a $5000 treatment plan. Her insurance policy limited maximum coverage to $1000 annually. The dental office sent a predetermination to the insurance company; the insurance carrier replied by stating that the patient had 50% coverage of her $5000 plan—which was NOT true.
Usually, dental offices find that a plan requires preauthorization for. Most dental insurance companies required to dentist to send a pre-approval notice for services which amount exceed $200.00 or more prior services are rendered. This dental insurance rules will not be listed on your dental insurance Benefit Book. Dental insurance pre-approval responses may last up to a month or more to be received which may significant slowdown or delay your treatment. This time-delay leaves time for patients to reconsider, lose interest, or forget the importance of the treatment plan.
A predetermination is redundant and takes up staff time. However, should the patient request an advance understanding of costs, we believe the best terminology to use is “pre-treatment estimate”—which clearly communicates that the sum is only one’s best calculation of the total costs for services and potential out-of-pocket costs to the patient.
A referral from my primary care physician and that it is up to me to obtain the referral. I understand that without this referral, my insurance will not pay for any services and that I will be financially responsible for all services rendered.
Referrals. Why sometimes you are referred out from a general practice to a specialist? Your general dentist can, in most cases, perform most of the same procedures a specialist performs. Depending on both the patient and dentist, this encompasses a wide-range of services – most anything from extracting teeth to cosmetic and restorative procedures. However, there may be a time that your general dentist will refer you to a specialist. The reason could be the complexity of a procedure, the patient’s health, or because your referral specialist will provider with extra specialized training and required special dental tools. After you are being treated by a specialist, patient may return to our office for continuing treatment.
PERCENTAGES
Regularly dental insurance organizes dental services by categories and percentages.
In most case, dental plans categories and percentages differ by employer, group, price, area, individual plans, among other dental insurances specifications.
Usually, Preventive services may include but not limited to, oral exam, teeth cleaning, and routine X-rays. These services often fall on those fully coverage by dental insurance but may vary in some specific dental insurance. While Basic dental services are covered from 15% to 100% (reg. 50%-80%). In general, basic services are typically those types of treatments and procedures that are relatively straightforward in nature and do not involve a significant insurance disbursement, ex. fillings, -as well often considered-: simple extraction, root canal, periodontal services, among others. Major dental procedures refer to services that are more extensive than root canals or fillings. Major dental services include crowns, bridges, and dentures—work that replaces missing or damaged teeth, coverage may fluctuate from 30% to 100% (reg. 50%)
UNDERSTANDING WAITING PERIODS AND MISSING TOOTH CLAUSE
Waiting periods are typically none on PPO’s dental plan; however, some PPO’s plan there is a waiting period that often runs 6 months for basic services and 6 to 12 months for major services. Missing Tooth Clause (MTC): If a dental insurance policy has a missing tooth clause, a tooth replacement will only be covered if a tooth was extracted or lost while the policy was active or in force. If a tooth was extracted during a period where a patient had no insurance or was covered by a different insurance company, an implant, partial denture, or bridge would not be paid for by the new plan.
If you do not have dental care coverage you are still welcome in our office as a non-insured patient. Non-insured patient is fully entitled to any dental services our office offers. Non-insured patient will not follow any percentage, waiting period or missing tooth clauses, as insured patient must, any needed treatment can be completed without restriction, and will follow our office non-insured fees.
Estimates: How this work for non-insured patients?
Based on our doctor evaluation, our team is here to help you get a price cost estimate for your dental services. In the spirit of transparency, and to meet current federal regulations, after doctor evaluation, we provide a document that lists gross charges for specific procedures and/or services determined and or suggested by our doctor. Your final costs may vary from this estimate for many reasons, including but not limited to additional services advised, required, or requested while performing treatment (s), or adjustments on your treatment plan due to noticeable changes of initial visit/previous diagnosis; ex, it may occur for prolonging or abandoning recommended treatments.
Non-insured patient will be asked to pay a full amount of your estimated charges before service is rendered. Note that additional fees for services rendered by our dentist at the time of your appointment, will be collected at time of your exit from office.
You may contact our office to discuss available payment options if procedure(s) is/are considered mayor (*) and takes more than one visit to be fully rendered.
(*) ex. of mayor procedures, implants, full dentures, bridges, crowns. (it may vary)