Types of Dental Plans/Benefit Details

Types of Dental Plans

Payment given to a doctor for providing services to a certain number of people. The amount paid depends on the number of patients.

Health Maintenance Organization is referred to as an HMO. A type of dental plan where the doctors agree to take a lesser fee for its members. HMO plans only cover if the patient sees the right HMO doctor.

Exclusive Provider Organization is also referred to as an EPO. Similar to an HMO. Lower out of pocket expense than a PPO for a patient, and no payment is made by plan if patient sees an out of EPO network doctor.

Preferred Provider Organization is also referred to as a PPO. A reduced fee-for-service plan that allows enrollees to visit any dentist, but encourages them to visit PPO network dentists to minimize out-of-pocket expenses. Enrollees usually pay less when visiting a PPO dentist.

Compensation paid to dentists based on an amount per service. A fee-for-service plan generally permits enrollees to freely select a network or non-contracted dentist to provide the service.

Government Funded Plans

Areas of Coverage

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    The areas of coverage listed in the categories below does not include a full and comprehensive list of all services within that category.
    The numbers written before the coverage area indicate the dental code numbers where that procedure can be found in a comprehensive list.

D0100-D0999 Diagnostic

Exams

X-rays

Tests

Oral Pathology

D1000-D1999 Preventive

Prophy

Fluoride

Sealants

Space Maintainers

Fillings

Inlays

Onlays

Crowns

Root Canals

Gum Treatments

D5000-D5899 Prosthodontics (removable)

Dentures

Partials

Repairs

D6200-D6999 Prosthodontics (fixed)

Pontics

Bridges

Retained Inlays

Retained Onlays

Veneers

 

Implants

Implant Crowns

Extractions

Orthodontic Services

Unclassified treatments/procedures

Areas of Coverage for Payment Purposes

Most plans cover 100% of preventive care and apply co-payments, either as a dollar amount (DHMOs) or as a percentage (DPPOs and Dental Indemnity/ or Traditional Insurance) to other levels of care. Preventative care usually includes periodic oral evaluations, x-rays and sealants. (NOTE: Sealants may be limited to certain age groups.)

Office visits, extractions, fillings, root canals, and periodontal treatment for gum disease, are typically covered at a lower percentage amount, for instance 80% (sometimes 60%), or with lower dollar co-payments in the case of a DHMO.

Crowns, bridges, inlays, and dentures are usually covered at the lowest percentage, such as 50% or a higher dollar co-payment in the case of a DHMO. Root canals are also sometimes covered in this category rather than as a Basic procedure, so check your coverage. Some carriers now offer coverage for implants under this category of coverage.

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    Did you know?

    Just under half of dental PPOs, the predominant dental product in the market, have a maximum annual benefit above $1500—half are less than $1500. Deductibles for these products are usually between $50 and $100.

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    Need more help with procedure codes and things to know when submitting claims?

    We LOVE Coding With Confidence by Charles Blair, D.D.S. Our other favorites are the CDT: Dental Procedure Codes and the CDT Companion Guides put out by the ADA each year. We recommend having those at your front office to ensure proper claim submissions.