Sudbury Smiles Dentistry
Dr. Alan Kwong Hing

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dental tips & fun facts

Understanding your Dental Insurance

Sudbury Smiles Dentistry Insurance Policy:

  • We accept all forms of insurance.

  • Our office does take assignment of benefits unless your dental plan carrier is strictly set up as non-assignment.

  • We accept privately funded dental plans, as well as Government, supported plans such as Ontario Works (OW), Ontario Disability Support Program (ODSP), Healy Smiles Ontario (HSO) and Non-insured health benefits for First Nations and Inuit (NIHB).

Understanding your Dental Insurance FAQS

 
 

What is assignment and non-assignment of benefits?

As a service to patients, a dental office may accept assignment of benefits whereby they agree to have the patient request that his or her dental plan provider (insurance company) pays the dental office directly for the percentage of the cost covered. The patient is responsible for paying the co-payment when treatment is provided.

In a non-assignment office, the patient is responsible for paying the full cost of treatment at the time it is provided. The dental office will assist the patient by providing a completed dental claim form that the patient can submit to their dental plan provider for reimbursement.

In some cases, a dental plan company will only reimburse the plan holder requiring the patient to pay for all costs at the time treatment is provided. In all circumstances, the patient is responsible for any charges not covered by his or her dental plan.

What is the dental plan co-payment?

The co-payment is the patient's portion of the cost of care. Dental plans are an employee benefit designed to offset the cost of dental care. Generally, a dental plan will only cover a portion of the cost of any treatment service—the patient is responsible for any charges not covered by the plan (the co-payment).

Your dentist has a legal and regulatory requirement to collect the co-payment from all patients.

How much do I have to pay?

This will depend on your plan coverage. Many plans will cover a percentage of costs for eligible services.

For example, a plan may cover 80 percent of the cost of basic/preventive services such as examinations, fillings, and cleanings. This percentage is based on the costs outlined by the plan provider and may vary from the actual costs of the treatment. Major procedures such as crowns, bridges, and dentures may be covered at 50 percent of the cost outlined by the plan.

You are responsible for any costs not covered by the plan. Review your dental plan to understand your coverage.

Why do I have to pay the co-payment?

Your dental plan is an agreement between you and your dental plan company that they will cover a percentage of the eligible treatment based on the details outlined in your plan. Both you and your dentist sign a claim to agree to the total cost of treatment. If you are not paying your share of the agreement, you are making a false declaration, as is the dentist.

A dentist must accurately reflect the percentage of the total cost that is being charged to the insurance company and collect the remaining costs from the patient.

Why do I have to pay for treatment when my plan covers it?

Dental offices are entitled to reimbursement for services at the time treatment is provided. A dental plan is a contract between a patient and their dental plan carrier.

As a service to patients, some offices will accept assignment of benefits whereby they agree to receive payment for the covered portion of treatment directly from the dental plan provider. Dental offices are not obligated to do so, and in some cases, are restricted from doing so as the dental plan carrier will only reimburse the patient.

The details of a patient's plan are protected by the Canadian Personal Information Protection Act (PIPA). Due to the restrictions of a dental office in knowing what is covered by their patients' plans, they may choose to have the patient pay them directly for all services. While the dental office will help with the claim, it is the patient's responsibility to know what is covered in their plan including any limits to the plan or changes; to pay for any costs not covered by the plan, and to seek reimbursement from their dental plan provider.

Why has my dental office asked for a deposit for treatment?

The dental office may incur various expenses in preparation for the commencement of your dental treatment. It is not uncommon for dental offices to request a deposit prior to treatment. Particularly on major dental work such as crowns, bridges, dentures and implants.

What is a pre-determination of benefits?

A pre-determination is an estimate of what treatment your dental plan will cover and what you will be responsible for. Your dental office will submit an outline of the proposed treatment to your dental plan provider before proceeding with treatment. It is an estimate only and does not guarantee the final costs you will be responsible for paying.

It is important for you to be well informed about your plan coverage. Check with your dental plan provider to clarify when a pre-determination is required. Some plans may only reimburse some services if a pre-determination is received in advance of treatment. Also, be aware that pre-determination may be valid for a limited time; what is covered can change if you reach the financial limits of your plan, and other changes can occur to your plan before treatment is completed.

Your dental plan carrier determines the final treatment coverage. Any costs not covered are your responsibility.

You can also request a pre-determination so that you do not go over your benefit maximum. Many patients request this for basic restorative services to that they are aware of what they may have to pay out of pocket.

Kortney Kwong Hing