Insurance coverage is an agreement between the insurance company and the place of employment. In Ontario alone, there are over 30,000 dental insurance plans that are unique in their benefits! Some plans cover as much as 100%, while others cover as little as 10%. This is why it is important to have an understanding of your plan ahead of scheduling an appointment. It is also important to be aware that your coverage may not be based on the current year’s fee guide (our office follows the current Ontario Dental Association fee guide), and the amount of coverage negotiated with your insurance company does not involve the dentist. This means patients are responsible for unpaid portions of dental procedures (co-payment). Patients are expected to cover the costs of any procedures that the insurance plan does not cover.
Waiving the co-payment is forbidden: Contrary to what some patients believe, dentists cannot waive the co-payment fee as this is insurance fraud. Insurance fraud can lead to very serious consequences.
Waiving the co-payment is forbidden: Contrary to what some patients believe, dentists cannot waive the co-payment fee as this is insurance fraud. Insurance fraud can lead to very serious consequences.
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What is the dental office responsible for?
We will provide you with the available treatment options and estimated costs, specifically per your needs and not according to insurance frequencies/limitations. Dental pre-determinations, also known as dental estimates, can be submitted by our dental office to your insurance provider. Pre-determinations can be thought of as a request to insurance providers, asking them to notify the patient what they should expect to be covered for procedures in the treatment plan. Due to privacy laws, the insured member will receive the response and not the dental office. Therefore, the patient is responsible for checking their pre-determination responses, and knowing their coverage prior to an appointment. We will submit your claim electronically on your behalf for quicker processing and payment.
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Paying Up-front vs. Paying the Difference
It is common for patients to wonder if they are expected to pay upfront for dental treatment (and get reimbursed by their insurance) or if they should simply pay the difference. This depends on the plan – some plans allow assignment of benefits (paying the difference) while others are non-assignment (paying upfront). You will have three payment options to choose from:
a) You pay for your service in full and collect from your insurance payment (usually within 48 hrs after electronic submission).
b) You pay for your co-payment (the portion not covered by insurance) and we accept direct payment from insurance (referred to as assignment).
c) You provide a credit card number and after we collect payment from insurance your card will be charged for any uncovered portion.
We will gladly provide and submit estimates for any major work to be done; but, once patient proceeds with treatment, the entire cost is their responsibility.
a) You pay for your service in full and collect from your insurance payment (usually within 48 hrs after electronic submission).
b) You pay for your co-payment (the portion not covered by insurance) and we accept direct payment from insurance (referred to as assignment).
c) You provide a credit card number and after we collect payment from insurance your card will be charged for any uncovered portion.
We will gladly provide and submit estimates for any major work to be done; but, once patient proceeds with treatment, the entire cost is their responsibility.
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Some patients are covered under two insurances. Please let reception know if you are enrolled under your partner’s plan (in addition to your own). At the completion of an appointment, our reception team will send out a claim to your primary insurance provider. If the primary insurance is covering less than 100% of the services, the response received will then be submitted to the secondary carrier. The secondary insurance will need to consider the primary coverage in order to assess the claim. The patient is responsible for any remaining balance not covered by both insurance plans. We will gladly help you with any insurance forms and additional information, especially, |
If you have more questions related to your dental coverage, your employer and/or insurance provider can answer any specific questions. For more information, call us at (905) 857 1430 or visit The Dental Smile Centre in Bolton, Ontario.