1. What is a “UCR” and how is it
determined?
“UCR” is the term used by insurance
companies to describe the amount they are
willing to pay for a particular endodontic
procedure. There is no standard fee or
accepted method for determining the UCR and
the UCR has no relationship to the fee
charged by your endodontist. The
administrator of each dental benefit plan
determines the fees that the plan will pay,
often based on many factors including region
of the country, number of procedures
performed and cost of living.
2. Why was my benefit different
from what I expected?
Your dental benefit may vary for a
number of reasons, such as:
• You have already used some or all of the
benefits available from your dental
insurance.
• Your insurance plan paid only a percentage
of the fee charged by your endodontist.
• The treatment you needed was not a covered
benefit.
• You have not yet met your deductible.
• You have not reached the end of your
plan’s waiting period and are currently
ineligible for coverage.
3. Why isn’t the recommended
treatment a covered benefit?
Your endodontist diagnoses and provides
treatment based on his or her professional
judgment and not on the cost of that care.
Some employers or insurance plans exclude
coverage for necessary treatment as a way to
reduce their costs. Your plan may not
include this particular treatment or
procedure, although your endodontist deemed
the treatment necessary.
4. How do I know what my payment
portion will be if my insurance does not
cover the entire fee?
Your payment portion will vary according to
the UCR of your plan, your maximum allowable
benefit and other factors. Ultimately, the
patient portion is not known until the
insurance check has been received by your
endodontist.
5. How do I understand my
Explanation of Benefits (EOB)?
Your Explanation of Benefits (EOB) is a
wealth of information. The EOB identifies
the benefits, the amount your insurance
carrier is willing to pay and charges that
are and are not covered by your plan. The
statement includes the following
information: UCR, copayment amount/patient
portion, remaining benefits, deductible and
benefit paid.
6. How long does it take for a
claim to be paid?
The time for a dental insurance
carrier to process an insurance claim
varies. At least 38 states have enacted laws
requiring dental insurance carriers to pay
claims within a timely period (ranging
generally from 15 to 60 days). If you want
to file a complaint about a delayed payment,
contact the insurance commissioner in your
state. They want to know if your insurance
company does not pay within the period
allowed by your state law.
7. Will my endodontist take my
insurance?
Most endodontists fall in one or more
categories, and there may be more options
than are described here. Some endodontists
sign contracts with dental insurance
carriers and agree to accept or “take” the
payment offered by the insurance company as
payment in full, even though it may not be
the same amount as the endodontist charges
for the procedure. These endodontists are
Participating Providers in your plan.
Other endodontists do not sign contracts
with dental insurance carriers but may still
accept or “take” insurance company payments.
These endodontists are not contractually
obligated to accept your insurance carrier’s
payment as full compensation and are not
Participating Providers. In this instance,
you may be responsible for a payment portion
over and above the percentage provided by
your insurance company.
Still other endodontists are not
Participating Providers and do not accept
payments directly from your insurance
carrier. In this case, your endodontist will
ask that you be responsible for the entire
fee but will assist you in filing your claim
to receive insurance benefits directly from
your insurance carrier.
8. What if I still have
questions?
Your endodontist will do his or her best to
answer all of your insurance questions.
Please keep in mind that there are many
insurance plans available and that your
employer chooses your plan and your
benefits. If you believe your benefits are
inadequate, you may want to discuss the
matter with your plan administrator and
explore appropriate alternatives.
