Can I Go to an Out-of-Network Dentist?

It is possible to seek dental care from a dentist not directly contracted with your insurance provider, known as an “out-of-network” dentist. This means the dental professional has not agreed to the specific fee schedules or terms set by your insurance company. While choosing an out-of-network provider offers flexibility in selecting a dentist, it typically involves different financial arrangements and administrative procedures compared to staying within your insurance network.

Understanding Your Dental Plan’s Out-of-Network Coverage

Before scheduling an appointment with an out-of-network dentist, review your specific dental insurance policy documents. These documents, often accessible through your insurer’s online member portal or a printed plan summary, detail how out-of-network services are covered. Contacting your insurance provider’s customer service line can also clarify specific aspects of your plan’s benefits.

A key term to understand is “Usual, Customary, and Reasonable” (UCR) rates. This represents the maximum amount your insurer will consider for payment for a dental procedure in a specific geographic area. Out-of-network dentists are not obligated to adhere to these UCR rates, meaning their charges may exceed what your insurance company deems customary. Your policy will outline how benefits are calculated based on these UCR amounts.

Deductibles also apply to out-of-network services, representing the initial amount you must pay out-of-pocket before your insurance begins to cover costs. For example, if your plan has a $50 deductible, you pay the first $50 of covered services before your insurer contributes. Many plans have separate or higher deductibles for out-of-network care compared to in-network care.

Coinsurance percentages dictate the portion of the covered service cost your insurance will pay after the deductible is met. For instance, a plan might cover 80% of in-network costs but only 50% of out-of-network costs, based on the UCR. You are responsible for the remaining percentage. Also note any annual maximums, which represent the total dollar amount your insurance will pay for covered dental services within a benefit period, regardless of network status.

Some dental plans include waiting periods for certain procedures, such as major restorative work, which can apply to both in-network and out-of-network services. These periods vary by plan and can range from a few months to a year or more. When communicating with your insurer, inquire about the UCR for specific procedures, how your deductible applies to out-of-network care, and any relevant waiting periods.

Financial Implications of Out-of-Network Care

Choosing an out-of-network dentist often results in higher out-of-pocket expenses compared to using an in-network provider. This is largely due to “balance billing,” where the out-of-network dentist charges their full fee, which may exceed the insurance company’s UCR rate. The patient is then responsible for the difference between the dentist’s charge and the insurer’s UCR, in addition to their deductible and coinsurance.

For example, consider a dental procedure an out-of-network dentist charges $1,000 for, but your insurance company’s UCR is $700. If your plan has a $50 deductible and 50% coinsurance for out-of-network services, you first pay the $50 deductible. Of the remaining $650 (UCR minus deductible), your insurance pays 50%, or $325. You are then responsible for the remaining $325 coinsurance plus the $300 difference between the dentist’s charge and the UCR ($1,000 – $700). In this scenario, your total out-of-pocket cost would be $50 (deductible) + $325 (coinsurance) + $300 (balance bill) = $675.

In contrast, for an in-network dentist, the contracted rate aligns with the insurer’s allowed amount, eliminating balance billing. Using the same example with an in-network dentist charging $700, and assuming a $50 deductible and 20% coinsurance for in-network services, your out-of-pocket cost would be $50 (deductible) + $130 (20% of $650) = $180. The difference in out-of-pocket expense can be substantial.

Higher costs for individual out-of-network services can cause you to reach your annual maximum benefit more quickly. Once the annual maximum is met, typically ranging from $1,000 to $2,000 for many plans, you become responsible for 100% of all subsequent dental costs for the remainder of the benefit period. This can significantly impact your ability to afford additional necessary treatments. Out-of-network dentists frequently require full payment at the time of service, unlike in-network providers who usually only collect the patient’s estimated copay or coinsurance.

The Reimbursement Process for Out-of-Network Services

When receiving care from an out-of-network dentist, the patient is responsible for submitting the claim directly to their insurance company. Unlike in-network providers who handle claim submissions as part of their agreement, out-of-network dentists do not file claims on your behalf. This means you will need to gather and submit all necessary documentation yourself.

The required documentation includes an itemized bill from the dentist. This bill must clearly list the services performed, the date of service, the fee for each procedure, and the appropriate Current Dental Terminology (CDT) codes for each treatment. Some insurance companies may require a completed dental claim form, which can be downloaded from their website or obtained by calling customer service.

Claims can be submitted through various methods, including mail, fax, or an online portal provided by your insurance company. Keep copies of all submitted documents, including the itemized bill and any claim forms, for your personal records. This ensures you have a reference in case there are questions or discrepancies regarding your claim.

Processing times for out-of-network claims can vary but range from a few weeks to over a month. Once the claim is processed and approved, reimbursement checks are sent directly to the patient, not to the dental office. This means you will receive payment from your insurer after you have already paid the dentist in full.

If a claim is denied or the reimbursement amount is less than anticipated, review the Explanation of Benefits (EOB) statement sent by your insurer. The EOB will detail what was covered, what was not, and why. If clarification is needed, contact your insurance company’s customer service department to understand the specific reasons for the denial or reduced payment.