What is a “UCR” and how is it determined?
“UCR” is the term used by insurance companies to describe the amount they are willing to pay for a particular endodontic procedure. There is no standard fee or accepted method for determining the UCR and the UCR has no relationship to the fee charged by your endodontist. The administrator of each dental benefit plan determines the fees that the plan will pay, often based on many factors including region of the country, number of procedures performed and cost of living.
Why was my benefit different from what I expected?
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.
Why isn’t the recommended treatment a covered benefit?
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.
How do I know what my payment portion will be if my insurance does not cover the entire fee?
Your payment portion will vary according to the UCR of your plan, your maximum allowable benefit and other factors. Ultimately, the patient portion is not known until the insurance check has been received by your endodontist.
How do I understand my Explanation of Benefits (EOB)?
Your Explanation of Benefits (EOB) is a wealth of information. The EOB identifies the benefits, the amount your insurance carrier is willing to pay and charges that are and are not covered by your plan. The statement includes the following information: UCR, copayment amount/patient portion, remaining benefits, deductible and benefit paid.
How long does it take for a claim to be 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). If you want to file a complaint about a delayed payment, contact the insurance commissioner in your state. They want to know if your insurance company does not pay within the period allowed by your state law.
Will my endodontist take my insurance?
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.
What if I still have questions?
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.