With your dental plan, you may have the option to see any practicing licensed dentist and receive benefits for covered services. However, some of these dentists may be in- or out-of-network with your dental plan. What does that mean? In-network dentists have agreed to a fixed rate by the dental insurer, resulting in more affordable and convenient care with your dentist filing a claim on your behalf. Out-of-network dentists do not participate with the dental insurer, so your costs may be higher as a result and you may have to file your own claim for reimbursement.
The chart below illustrates why it's to your advantage to get your dental care through an in-network dentist:
| In-network dentists | Out-of-network dentists | |
|---|---|---|
| Reduced Treatment Fees | Yes | Maybe |
| Submit Claims on Member's Behalf | Yes | Maybe |
| Issue Resolution | Yes | Maybe |
Let's review these items in more detail:
In agreement with the dental insurer, dentists must agree to reduce their normal charges for that plan's members. These contractually negotiated fees are significantly reduced and therefore members save money when they receive care from in-network dentists.
In addition, in-network dentists must not bill for additional costs beyond those contractually negotiated fees. If they do, this is called “balance billing” and is prohibited.
Remember that these contractually negotiated fees generally apply only to covered services. However, it is worth asking an in-network dentist if they are willing to extend their lower treatment charges for services that are not covered by your dental plan.
In-network dentists will submit claims on a plan member's behalf. This makes your dental experience much more convenient. Be sure to present your insurance card for all dental visits to insure that your dentist has the information needed to work with your dental plan to submit claims on your behalf.
In-network dentists typically undergo a safety and quality review process known as credentialing. Your plan reviews a variety of data sources to ensure that the dentist meets important quality standards. This includes a review of the dentist's license and specialty certifications, liability coverage, malpractice history, billing patterns, and treatment quality outcomes.
Many dental plan administrators use technology and processes to ensure that in-network dentists treat and bill members appropriately. When treatment or billing irregularities are identified, dental plans typically work with an in-network dentist to better understand the circumstances. When these patterns suggest poor treatment or abuse, a dentist will typically be closely monitored or removed from the network. This oversight helps manage plan costs and gives members greater confidence in the qualifications and reliability of their in-network dentists.
Your dental plan administrator can help you resolve concerns or grievances with in-network dentists. This may include:
