Determining How Much Your Plan Pays

UCR fees and balance billing

Usual, Customary & Reasonable (UCR) is the common term for fee guidelines insurance companies use to pay claims. UCR guidelines were put in place to help control dental inflation.

It is important for you to understand what level of UCR your plan pays because it can impact the payment of your claim. If your plan pays up to the 90th percentile, this means that 90% of dentists in a given area charge that fee or less.

Geographic differences in fees

UCR fee levels differ from one geographic area to another. The following map shows some sample fees for a crown in different areas of the country. The figures used are at the 50th percentile.

Major US cities and associated fees for a crown.

The Fee Lookup feature will assist you by providing you with a benchmark to better understand whether your dentist's charges are reasonable.

The following information describes how UCR fee schedules and balance billing can impact your claim:

• If a dentist's fee is below the UCR level, UCR will probably not impact your claim because plans generally pay the lesser of UCR or the dentist's actual fee.
• If a dentist's fee exceeds the UCR level, the dentist can bill you for the difference between his or her charge and the amount allowed by the plan. This is commonly referred to as balance billing.

The following examples are for education only. Please refer to your dental plan summary for specific information.

The UCR fee at the 90th percentile in the following example is $800.

Co-insurance

Co-insurance refers to the percentage the insurance company or administrator and the patient are responsible for. The co-insurance generally applies after the deductible has been met and only applies to covered expenses.

The examples on this page are for education only. Please refer to your dental plan summary for specific information.

Following is a typical breakdown for co-insurance payments.

The impact of co-insurance on a standard claim is illustrated in this example:

Co-insurance applies differently to Preferred Provider Organization (PPO) and non-PPO claims.

• The co-insurance for a PPO dentist is based on the discounted fee. In the example below, the co-insurance is applied after the PPO dentist's discount.
• The co-insurance for a non-PPO dentist is based on the lesser of the dentist's fee or the usual, customary and reasonable fee. Non-PPO dentists do not discount their fees.

In this example, you can see the impact of co-insurance on a PPO claim:

Visiting a PPO dentist typically results in lower out-of-pocket expenses. As shown in the example, the patient saved $90 by using a PPO dentist. Please refer to your dental plan summary for specific information about your benefits.