Dental Insurance Frequently Asked Questions

The Encore Smiles Plan

1. I see the office offers the Encore Smile Plan. Is this a dental insurance plan?

The Encore Smile Plan is NOT dental insurance but it is a plan carefully designed to provide similar or better value that dental insurance provider exclusively to our patient base while keeping use of the plan easy to use and understand. Dental insurance providers often have hard to understand benefit structure, exclusions and limitations, requirements for pre-authorizations, etc.

For more information and details about the Encore Smiles plan and how the plan delivers value, you can CLICK HERE to visit the page.

Understanding Your Dental Benefits

2. What is a PPO plan, and what does it mean that you are “in-network?”

A PPO (Preferred Provider Organization) plan offers a network of dentists who have agreed to charge discounted, pre-negotiated fees for services. You will receive the maximum benefit (highest coverage) and pay the lowest out-of-pocket costs when you visit us provided, we are in-network.

3. How does an “Annual Maximum” work?

The Annual Maximum is the maximum dollar amount your dental insurance company will pay for your dental care within one plan year (usually a calendar year). Once this limit is reached, you are responsible for 100% of the cost of any further treatment until the next plan year begins.

4. What is a “Deductible,” and does it apply to all services?

A Deductible is the set dollar amount you must pay out-of-pocket each plan year before your insurance company begins to pay for any covered services. For most PPO plans, the deductible does not apply to preventive services like cleanings and exams, but it does apply to basic and major services (fillings, crowns, etc.).

5. What is “Coinsurance” and how is it different from a Copay?

Coinsurance is your percentage of the cost for a covered service after you have met your deductible. For example, if your plan covers a filling at 80%, your coinsurance is 20%. A Copay is a fixed dollar amount you may owe for a service, which is common in DHMO plans, but less common in PPOs.

6. Do I need a referral to see a specialist (like an Oral Surgeon or Endodontist)?

No. A major benefit of PPO plans is that you do not need a referral from our office to see any dental specialist. However, we highly recommend you see a specialist who is also in-network with your PPO plan for the greatest savings.

7. My insurance covers two cleanings per year. When can I get them?

Most plans cover two cleanings (prophylaxis) per benefit period or plan year. However, some plans specify a cleaning must be performed once every six months, plus one day. We will check your specific plan frequency when scheduling to ensure your visit is covered.

Office and Billing Procedures

8. Will you file my claim for me?

Yes! As a courtesy to our patients, we will submit all necessary claims and supporting documentation (like X-rays and notes) directly to your dental insurance provider on your behalf.

9. What information do I need to provide about my insurance?

Please bring your dental insurance card and a valid form of ID to your first appointment. We will need the insurance company’s name, the member’s ID number, and the group number.

10. Why do you need my social security number, or the policy holder’s SSN?

In some cases, to accurately verify your benefits and ensure the claim is processed correctly, your insurance carrier may require the subscriber’s (policy holder’s) date of birth and social security number as a unique identifier. This is a common

requirement and all data is handled securely.

11. Will you check my benefits for me before my visit?

Yes, we will contact your insurance company for a breakdown of benefits as a courtesy. However, please remember that the benefits quoted to us are never a guarantee of payment, as the insurance company makes the final decision when the claim is processed.

12. Why do I have a co- payment if you are in- network?

Your co-payment or estimated patient portion is the part of the service cost that your insurance plan has determined is your responsibility (such as the deductible, coinsurance percentage, or a non-covered service) . We collect this estimated amount at the time of service.

13. What is an “Explanation of Benefits” (EOB)?

The EOB is a statement your insurance company sends to both you and our office after a claim has been processed. It is not a bill, but a detailed report showing: the total charged, the negotiated in-network discount, the amount the plan covered, and the remaining amount you are officially responsible for.

14. What happens if the insurance company pays less than my estimate?

If your insurance pays less than our initial estimate, you will receive a statement from our office for the remaining balance. Dental insurance is a contract between you and your carrier, so the patient is ultimately responsible for any amount not covered by the plan.

Treatment and Limitations

15. What is a “Pre-Treatment Estimate” (Predetermination)?

A Pre-Treatment Estimate is a request we submit to your insurance company for major procedures (like a crown or bridge) to get a written estimate of what they will cover before treatment begins. This is highly recommended for costly services to help you plan your out-of-pocket

expenses.

16. Does my insurance plan cover cosmetic procedures like teeth whitening?

Most standard dental insurance plans focus on functional, restorative, and preventive care. Cosmetic procedures like teeth whitening or veneers are generally not covered by dental insurance. We will clearly communicate any non-covered costs before treatment.

17. Why did my insurance only pay for a silver (amalgam) filling instead of a white (composite) filling?

Some dental plans have an “Alternate Benefit Clause” where they will only cover the cost of the least expensive alternative procedure. For back teeth, they may only cover the cost of a silver filling, even if a white filling is used, and the patient is responsible for the difference in cost.

18. Does my PPO plan have waiting periods for certain services?

Waiting periods are common for new plans, especially for major services (e.g., 6 months for basic, 12 months for major). If you had prior coverage in Georgia, your new carrier may waive or shorten the waiting period (a process called “credit for prior coverage”). We will check this for you.

19. What if I have two dental insurance plans (Dual Coverage)?

If you have two plans (e.g., one through your employer, one through your spouse), we will coordinate benefits following the Coordination of Benefits (COB) rule. The plan under which you are the primary member is usually the Primary Insurance. We file to the primary plan first, and the secondary plan may cover a portion of the remaining balance, up to 100% of the total cost.