When a dentist charges the member for costs above the dental insurance plan's allowable amount, it is often referred to as balance billing. Generally, a dental insurance plan's allowable amount for services from in-network dentists equals the fees that these dentists agree to accept when joining a dental insurance plan administrator's network. Because in-network dentists must accept these contracted fees as payment in full, balance billing the member for the difference between the allowable amount and the dentist's usual charge is not allowed. When a member visits an out-of-network dentist, the dental insurance plan's allowable amount may be less than the dentist's charge. When this happens, out-of-network dentists may balance bill members for the difference.
Benefit
This is the amount paid by a dental insurance plan sponsor or administrator for covered dental services. The benefit may be paid to the dental insurance plan member or directly to the dentist if the dental insurance plan member has assigned their benefits to the dentist.
Benefit reimbursement
This is the payment that a dental insurance plan administrator makes to a dental insurance plan member, or to a dentist on behalf of a dental insurance plan member.
When parents or guardians each cover their dependents on their dental insurance plan, dental insurance plan administrators use a Coordination of Benefits provision called the birthday rule to determine which dental insurance plan should be the primary and secondary dental insurance plan (i.e. which dental insurance plan pays benefits first). The birthday rule stipulates that the parent or guardian whose date of birth falls first in a calendar year regardless of age is considered the primary payor. You should read your dental insurance plan documents or consult with an HR or benefits consultant for a full understanding of how the provision is applied.
