Insurance FAQ

Dental and Medical Insurance is provided through your employer or you are self-insured.

Insurance helps you cover a percentage of the costs for covered procedures. To find out if certain procedures are covered you should contact your employer or insurance carrier.

Each dental insurance company plan has a different combination of benefits and limitations. Plans have Standard Coordination of Benefits or Non–Duplications of Benefits. Some have UCR Plans or Fee Schedule Plans. Each plan may or may not have an Annual Maximum and/or an Annual Deductible. All insurance companies follow the “Birthday Rule.”

Dental Insurance Provider

Dr. Fagin is an in-network preferred provider most of the Insurers in the San Mateo area. Patients seeing Dr. Fagin will pay their estimated co-payment at the time of service. We will send you a statement for the remaining balance for any treatment not covered by your insurance for any reason or delay.  Your insurance carrier will mail you an Explanation of Benefits (EOB) and limitations of your dental coverage.

Medical Insurance

We bill all medical carriers, except for HMO plans and Medicare. HMO medical carriers will not pay us for our services because we are not an in-network provider. With Medicare most dental procedures are not covered, as a result we have opted-out.

Some dental insurance plans have coordination of benefits with medical; hence we are required to submit claims to medical first. If you are seeking treatment due to an accident, please inform an administrator.

Billing and Reimbursement Protocol

In order for us to get started on billing your insurance we will need to complete subscriber and patient information. Unfortunately, if we do not receive complete insurance information we will be unable to submit your claim and will request payment in full on the day of service.

Please let us know if you want us to pre-authorize any procedures. Pre-authorizations take 4-8 weeks to process. Upon receipt we will send you a letter stating the ESTIMATED portion insurance will cover, along with any co-payment for the responsible party. Please note, pre-authorizations are not a guarantee of benefits. Credits on your account are refunded at the end of the month. If you have any billing or insurance questions please feel free to contact our office and ask for our dental or medical insurance coordinator.

Vocabulary

Annual Deductible – The dollar amount of expenses the insured must pay each year from their own pocket before the plan will reimburse them. The deductible is subtracted from the total claim right off the top. Once the deductible has been met, insurance will then base payment on the remaining balance.

Annual Maximum – The maximum dollar amount a dental plan will pay toward the cost of dental care incurred by an individual or a family in a specified period, usually a calendar year, as specified in the plan contract provisions.

Birthday Rule – Determines which insurance plan is primary when the patient is covered by more than one insurance plan. Referenced when the patient is a child the “Birthday Rule” identifies the primary insurer as the parent whose birthday falls first by month and day on the calendar year.

In-Network – This means that the doctor has agreed to charge fixed fees for each procedure rendered to the insurance company. Therefore, the benefit percentage might or might not be higher than an out-of network doctor.

Medicare – Medicare does not cover Dental procedures; therefore we have opted-out of Medicare meaning that we, including the patient, will not bill Medicare for any procedure performed by Dr. Fagin.

Pre-authorization – Statement by a third-party payer indicating proposed treatment will be covered under the terms of the benefit contract dependent upon service provided and further review.

Standard Coordination of Benefits – Determining which insurance is the primary payer and assuring that not more than 100 percent of the charges are paid to the provider and/or patient.

“Usual, Customary, and Reasonable” (UCR) Plans – A dental benefit plan that determines benefits based on “Usual, Customary and Reasonable” fee criteria.

Usual Fee – The fee that an individual dentist most frequently charges for a given dental service.

Customary Fee – The fee level determined by the administrator of a dental benefit plan for a specific dental procedure to establish the maximum benefit payable.

Reasonable Fee – The fee charged by a dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances, and therefore may differ from the dentist’s “usual” fee or the benefit administrator’s customary fee.