Dental Insurance Options Palo Alto CA
At Azeem K. Lakha, D.M.D. & Scott C. Baird, D.M.D. Diplomates, American Board of Oral & Maxillofacial Surgery. we make every effort to provide you with the finest care and the most convenient financial options. To accomplish this we work hand-in-hand with you to maximize your insurance reimbursement for covered procedures. If you have any problems or questions, please ask our staff. They are well informed and up-to-date. They can be reached by phone at Palo Alto Office Phone Number 650-328-6622.
Please call if you have any questions or concerns regarding your initial visit.
Please bring your insurance information with you to the consultation so that we can expedite reimbursement.
FAQ – Dental Insurance
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-Duplication of Benefits, along with Incentive Plans or Indemnity Plans. 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.”
Dr. Lakha and Dr. Baird are in-network preferred providers with Delta Dental only. Delta Dental patients 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. Delta Dental will mail you an Explanation of Benefits (EOB) and limitations of your dental coverage.
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 of our 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 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, preauthorizations 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.
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 plans 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.
Divorce– When the patient is a dependent child of legally separated or divorced parents and is in the custody of one parent, that parent will be prime. Stepparent’s coverage is secondary, Non-custodial parent is third, and Non-custodial stepparent is fourth.
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.
Incentive Plans– A dental benefit plan that pays an increasing share of the treatment cost, provided that the covered individual utilizes the benefits of the program during each incentive period (usually a year) and receives the treatment prescribed. For example, a 70%-30% co-payment plan in the first year of coverage may become an 80%-20% program in the second year if the subscriber visits the dentist in the first year as stipulated in the program.
Non-Duplication of Benefits– This may apply to a patient that is eligible for benefits under more than one plan. A dental benefit contract provision relieving the third-party payer of liability for the cost of services are covered under another plan. Distinct from the coordination of benefits provision, because reimbursement would be limited to the greater level allowed by the two plans, rather than a total of 100% of the charges.
Opted-Out – we have signed a contract with Medicare stating that we, including the patient, will not bill them for any procedures performed by Dr. Lakha and Dr. Baird.
Out-of-Network– This means the doctor can set his owns fees for each procedure provided to his patient. The benefit percentage might or might not be lower than an in-network doctor.
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.
“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.
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