How to Determine Primary and Secondary Dental Insurance

Dental insurance helps individuals manage the costs of oral health. Many people find themselves covered by more than one dental insurance plan, often through a combination of their own employment benefits and a spouse’s or parent’s plan. While having multiple plans might seem to suggest double the coverage, it instead introduces a structured process to determine which plan pays first and how benefits are applied. This system ensures that claims are processed efficiently and fairly across all active coverages.

The Concept of Coordination of Benefits (COB)

When an individual holds more than one dental insurance policy, Coordination of Benefits (COB) comes into play. COB is the industry standard for determining the order in which multiple plans pay for dental services. Its primary purpose is to prevent overpayment on claims, ensuring that the total benefits received from all plans do not exceed the actual cost of the dental procedure. This coordination also streamlines the claims process, helping to distribute the financial responsibility appropriately among the involved insurers.

COB rules establish a clear hierarchy, designating one plan as primary and others as secondary, or even tertiary, to ensure an organized flow of payments. Without COB, a patient could theoretically receive more than 100% of the cost of a service, which would be an inefficient use of insurance resources. This structured approach provides clarity for patients, dental providers, and insurance carriers, making the complex landscape of multiple coverages manageable. COB provisions are typically included in group dental plans.

Standard Rules for Primary and Secondary Determination

Determining primary and secondary dental insurance relies on established industry rules. These rules ensure consistency regardless of carriers. Understanding these guidelines helps individuals anticipate claim processing with multiple coverages.

One common guideline for dependent children covered by both parents’ plans is the “Birthday Rule.” Under this rule, the dental plan of the parent whose birthday occurs earlier in the calendar year is considered primary. It is important to note that only the month and day of birth are considered, not the year of birth. For instance, if one parent’s birthday is in March and the other’s is in July, the plan of the parent with the March birthday would be primary. Exceptions to this rule can occur if both parents share the same birthday, in which case the plan that has been active longer typically becomes primary.

When an individual is covered by their own employer-sponsored plan and also as a dependent on a spouse’s plan, their own employer’s plan is generally considered primary. This principle extends to scenarios where an individual holds two jobs, each providing dental benefits; the plan they enrolled in first is usually designated as primary. This “active employment” rule prioritizes coverage directly earned by the individual.

In situations involving a COBRA plan, which allows for continuation of health coverage after employment changes, and an active employer-sponsored plan, the active employment plan is typically primary. Similarly, an active employment plan generally takes precedence over a retiree plan. However, if a patient has both a retiree plan and Medicare, Medicare usually becomes primary once the patient turns 65.

Court orders, particularly in cases of divorce or separation, can override standard COB rules for dependent children. If a court decree specifically outlines which parent is responsible for providing primary dental coverage, that legal mandate takes precedence over rules like the Birthday Rule. Additionally, if a dental procedure is covered under both a medical plan and a dental plan, the medical plan is often considered primary, especially for services like oral surgery or trauma-related care.

Claim Submission and Payment with Multiple Plans

Once the primary and secondary dental insurance plans have been identified, the process for submitting and receiving payment for dental claims follows a specific sequence. Patients and dental offices must understand this order for timely and accurate benefit disbursement. The process begins with the initial claim submission to the primary insurer.

The dental office submits the claim for services to the primary dental insurance carrier. This submission includes all necessary procedure codes and treatment details. The primary insurer then processes the claim according to its policy terms, deductibles, and coverage limits, paying its portion of the allowed charges.

After the primary plan has processed the claim and issued its payment, it generates an Explanation of Benefits (EOB) document. This EOB details the services covered, the amount paid by the primary insurer, any amounts applied to deductibles or co-insurance, and the remaining balance. The EOB communicates the primary plan’s adjudication of the claim.

The dental office then submits the claim, along with a copy of the primary plan’s EOB, to the secondary dental insurance carrier. The secondary plan reviews the claim and the primary EOB to determine what additional benefits it will cover, typically up to its own policy limits or usual and customary fees. The combined payment from both the primary and secondary plans will not exceed the total cost of the dental services.

After both plans have processed the claim, any remaining balance becomes the patient’s responsibility. This remaining balance might include deductibles, co-insurance, or charges for services not covered by either plan. Understanding EOBs from both insurers is important for patients to track payments and their financial obligations. Patients should communicate their multiple coverages to their dental provider’s office to help ensure claims are submitted correctly from the outset, facilitating a smoother billing experience.