Insurance Overview

Choose a Network Dentist

Your dental insurance plan may offer you the option to see any practicing licensed dentist and receive benefits for covered services. However, some of these dentists may participate in a provider network offered by your dental plan administrator. What does that mean? In-network dentists have agreed to a fixed rate by the dental insurer, resulting in more affordable and convenient care with your dentist filing a claim on your behalf. Out-of-network dentists do not participate with the dental insurer, so your costs may be higher as a result and you may have to file your own claim for reimbursement. Some dental insurance plans only provide limited or no coverage for services received from out-of-network dentists. It is important to review your benefit plan summary to understand how your plan reimburses for out-of-network benefits.

In-network dentists must pass an ongoing screening process

To give members a greater sense of confidence in the qualifications and reliability of in-network dentists, in-network dentists generally undergo a review process known as credentialing. Your insurance plan's administrator, or an independent third party, reviews a variety of data sources to ensure that the dentist meets important standards. This includes a review of the dentist's license and specialty certifications (such as periodontists, endodontists, pediatric dentists, and oral surgeons), liability coverage, malpractice history, and more. This process is typically repeated every two to three years.

In-network dentists often significantly reduce their charges

To participate in an insurance plan administrator's network, dentists must agree to reduce their normal charges for that plan's members. Because these negotiated in-network treatment charges tend to be significantly reduced, members often reduce their out-of-pocket expenses and save a lot of money when they receive care from in-network dentists.

In addition, in-network dentists must not bill for additional costs beyond those reduced treatment fees. If they do, this is called "balance billing" and is prohibited.

Remember that these reduced charges generally apply only to covered services. However, it is worth asking an in-network dentist if they are willing to extend their lower treatment charges for services that are not covered by your dental plan.

In-network dentists are typically monitored

Many dental insurance plan administrators use technology, such as artificial intelligence, and a process called utilization review to ensure that dentists treat and bill members appropriately. When treatment or billing irregularities are identified, such as unbundling, overcoding, or upcoding, plan administrators may work with the dentist to better understand the circumstances. If the improper behavior persists, in-network dentists may be removed from the plan administrator's network. This oversight helps manage insurance plan premiums and claim costs. It also gives covered members greater confidence in the qualifications and reliability of in-network dentists.

In-network dentists typically submit claims on your behalf

Most in-network dentists will submit claims on a plan member's behalf. This makes your overall plan experience much easier. For your dentist to submit claims on your behalf, they will typically ask you to sign an "Assignment of Benefits" form to allow the insurance plan administrator to make payment directly to them. By doing so, the dentist can keep you out of the insurance transaction and only bill you for your out-of-pocket cost once the insurance transaction is settled. It is important to look at the detailed Explanation of Benefits from the insurance plan administrator to be sure you were charged the appropriate amount. Some dental insurance plans may not accept assignment of benefits, but will encourage or require in-network dentists to submit claims on the plan member's behalf.

Plans will support you if any issues arise

Your dental insurance plan administrator will assist you in resolving billing and other concerns or grievances with in-network dentists. They might not provide the same assistance when services are provided by an out-of-network dentist.

The chart below highlights some of the advantages of using an in-network dentist.

	In-network dentists	Out-of-network dentists
Ongoing Screening Process	Yes	No
Reduced Treatment Fees	Yes	No
Submit Claims on Member's Behalf (and Assignment of Benefits)	Usually	Varies
Issue Resolution Assistance	Yes	Varies