UCR (Usual, Customary, and Reasonable) is the term used by insurance companies to describe the amount they are willing to pay for a particular procedure. There is no standard fee or accepted method for determining the UCR. The fee your endodontist charges has no relationship to the UCR. Your dental benefit plan administrator establishes the percentages that they will pay for each procedure. These decisions are often based on many factors: region of the country, number of procedures performed and cost of living.
Your dental benefit may vary for a number of reasons, such as:
- You have already used some or all of the benefits available from your dental insurance.
- Your insurance plan paid only a percentage of the fee charged by your endodontist.
- The treatment you needed was not a covered benefit.
- You have not yet met your deductible.
- You have not reached the end of your plan’s waiting period and are currently ineligible for coverage.
Your endodontist diagnoses and provides treatment based on his or her professional judgment and not on the cost of that care. Some employers or insurance plans exclude coverage for necessary treatment as a way to reduce their costs. Your plan may not include this particular treatment or procedure, although your endodontist deemed the treatment necessary.
Prior to treatment, your endodontist will check your benefits and give you an estimate of what your out of pocket cost is going to be. Your payment portion will vary according to the UCR of your plan, your maximum allowable benefit and other factors.
Your Explanation of Benefits (EOB) identifies the benefits, the percentage your insurance carrier is willing to pay and charges procedures that are and are not covered by your plan These statements include the following figures: UCR/percent coverage, copayment amount/patient portion, remaining benefits, deductible and benefit paid.
The time for a dental insurance carrier to process an insurance claim varies. At least 38 states have enacted laws requiring dental insurance carriers to pay claims within a timely period (ranging generally from 15 to 60 days).
Most endodontists fall in one or more categories, and there may be more options than are described here. Some endodontists sign contracts with dental insurance carriers and agree to accept or “take” the payment offered by the insurance company as payment in full, even though it may not be the same amount that the endodontist charges for the procedure. These endodontists are Participating Providers in your plan.
Other endodontists do not sign contracts with dental insurance carriers but may still accept or “take” insurance company payments. These endodontists are not contractually obligated to accept your insurance carrier’s payment as full compensation and are not Participating Providers. In this instance, you may be responsible for a payment portion over and above the percentage provided by your insurance company.
Still other endodontists are not Participating Providers and do not accept payments directly from your insurance carrier. In this case, your endodontist will ask that you be responsible for the entire fee but will assist you in filing your claim to receive insurance benefits directly from your insurance carrier.
Your endodontist will do his or her best to answer all of your insurance questions. Please keep in mind that there are many insurance plans available and that your employer chooses your plan and your benefits. If you believe your benefits are inadequate, you may want to discuss the matter with your plan administrator and explore appropriate alternatives.