Categories of dental services
- Preventive, Basic and Major procedures. | Definitions & coverage levels. | Pre-treatment authorization.
Dental plans typically group covered procedures into categories that are referred to as: a) Preventive , b) Basic and c) Major services.
The category to which a procedure has been assigned typically indicates the amount of coverage (level of benefits) that the policy provides.
Policies can vary.
While the information we present on this page is typical of most plans, yours may categorize procedures or provide benefits differently.
To find out, you might read your plan's handbook or call your insurer's toll-free number. Probably the best way is to simply ask your dentist's front-office staff for help.
A) Preventive dental services.
You'll probably find that your benefits for Preventive (and Diagnostic) dental services are comparatively high.
It's common for indemnity insurance and preferred-provider (PPO's) plans to provide coverage at around 70 to 80% of your dentist's bill (using either a "UCR" or "Table of Allowances" calculation - see below). And in many cases it may even run 100%.
You'll need to check your policy to see if its deductible must be met before you receive any benefits. In many cases you will not.
With an HMO plan, you can expect that you'll have little or no copayment when Preventive procedures are performed.
List of Preventive / Diagnostic dental services.
- cleanings (prophylaxis)
- bitewing x-rays
- periapical x-rays
- full-mouth, panorex x-rays
- fluoride treatments
- space maintainers (may be a Basic service)
- tooth sealants (may be a Basic service)
Ideally your plan will provide these services at least at these frequencies.
- Examinations - twice per year.
- Bite-wing x-rays - once per year.
- Teeth cleanings - twice per year.
- Full mouth x-ray series - once every three years.
Additional preventive dental care for children and adolescents.
- Topical fluoride treatments - twice per year.
B) Basic dental services.
In general, basic services are typically those types of treatments and procedures that are relatively straightforward in nature and don't involve a significant laboratory expense for the dentist.
It's common for indemnity and PPO insurance plans to cover Basic services at a rate of about 80%. In most cases, benefits are not paid until the member has met their deductible. With HMO plans, a modest copayment may be required when these services are performed.
List of Basic dental services.
- emergency care for pain relief
- amalgam fillings
- composite fillings (white fillings)
- sedative fillings
- routine tooth extractions
- root canal treatment
- periodontal scaling and root planing
- periodontal surgery (may be Major service)
- recementing dental crowns
- stainless steel (prefabricated) crowns
C) Major dental services.
The Major dental services category typically includes procedures and treatments that are relatively more complex in nature and often involve a dental laboratory expense. These services tend to be more costly than those found in the Basic category.
With indemnity and PPO insurance policies, the benefits provided for Major dental services frequently run on the order of 50% of the procedure's cost, after the deductible has been met. With HMO plans a copayment is typically required.
List of Major dental services.
- crowns (may be a Basic service)
- inlays and onlays
- tooth implants
- impacted wisdom teeth removal (may be Basic)
- complex oral surgery procedures
- removable partial dentures
- complete dentures
- denture relines and rebases
- denture repair
- orthodontic treatment
Calculating what your actual benefits will be.
The following descriptions outline how dental insurance (indemnity) and PPO plans usually work.
A) Policies that calculate benefits using UCR fees.
Benefits that are based on procedure "UCR" fees ("Usual, customary, reasonable") are calculated on a percentage basis.
!! These calculations aren't quite as straightforward as you might expect. If this is the type of policy that you have, you should use our link above to learn more and read through some sample calculations.
As outlined above:
- Some types of dental procedures, such as Preventive and Diagnostic dental services (cleaning, x-rays), may be covered at a very high percentage (80 to 100%) of the UCR fee.
- Basic services (routine dental procedures) are usually covered as a slightly lower percentage (often 50 to 80%).
- Major dental services, such as dentures and crown and bridge treatment, if covered, will typically be provided for at an even lower rate (possibly 50% or less).
The dollar amount of benefits paid will be limited by your policy's stated deductible and maximum benefits. You're responsible for paying your dentist the difference between what your insurance has paid and the actual cost of your treatment.
B) Policies that base benefits on a Table of Allowances.
Some insurance policies calculate their benefits using a fixed fee schedule termed a "Table of Allowances."
This table is simply a listing of all covered dental procedures and the dollar amount that the insurance company will provide as a benefit when they are performed. Keep in mind, the amount paid will be limited by the policy's deductible and plan maximum benefits.
If you are considering a plan that uses a Table of Allowances, you should inquire as to whether the payments it specifies will be accepted by the treating dentist as payment in full, or you will be expected to make up the difference by way of making a copayment (the more likely arrangement). There can be a very significant out-of-pocket difference between the two.
Ask your dentist's office staff for help in determining your benefits.
For the dental patient, trying to calculate policy benefits can be both very confusing and very difficult to get right. So, don't hesitate to ask your dentist's staff for help or clarification.
- It's normal and routine for them to make these types of calculations. What patient wouldn't want to know what their costs will be before having a procedure performed?
- In many cases, they may be so familiar with the plan you have (because other patients do too) that they can come up with the right figure off the top of their head.
Of course, the ultimate authority on this issue is your insurance company. You do have a contract with them and certain treatment obligations are outlined in it. But with some procedures (especially Major services), the conditions under which they are covered may be open to the insurance company's interpretation.
So, and especially in situations where larger sums are involved, your dentist's office may feel that they should submit for pre-treatment authorization.
In this situation, your dentist will file a predetermination form that details specifics about your proposed treatment plan (they may also send x-rays, pictures or study models). In response, the insurance company will send an itemized reply stating what your expected benefits for each procedure should be.
This is usually a free service. (Filling out the form is an extension of goodwill on the part of your dentist. Making the calculation is one of your company's obligations to you as a plan member.) Turnaround time for the process is usually 2 to 3 weeks.
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