FAQ

Dental offices are entitled to reimbursement for services at the time treatment is provided. A dental plan is a contract between a patient and/or their dental plan carrier. As a service to patients, some offices will accept assignment of benefits whereby they agree to accept 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 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.

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 pay the dental office directly for the percentage of the cost covered. The patient is responsible for paying the co-payment when treatment is provided. See also: What is the dental plan co-payment?

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 costs not covered by his or her dental plan.

Understand your dental plan. Know what coverage you have so that you can make informed decisions on what dental treatment services are covered and what treatment costs you are responsible for. Speak to your dentist about the treatment options and the importance to your health so you can make an informed choice for your health needs.

Your dental office can work with you to provide an estimate and obtain a pre-determination prior to proceeding with treatment; however, they are not experts on your plan. Ensure you are aware of any changes and/or limits to your coverage and have let your dental provider know.

Prevention is the best way to maintain good dental health and reduce the need for more costly and complex treatment in the future. Practice good oral hygiene at home and visit the dentist regularly to identify issues early.

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 prior to 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 on 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-determinations may be valid for a limited time; what is covered can change if you reach the financial limits of your plan; and/or other changes can occur to your plan before treatment is completed.

The final treatment coverage is determined by your dental plan carrier. Any costs not covered are your responsibility.

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.

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. See also: How can I find out what my dental plan covers?

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 costs not covered by the plan (the co-payment).

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

If you do not benefit from a dental plan provided by your employer you may wish to consider purchasing a dental plan to help offset some of the costs of care. This is particularly valuable in accessing preventive services.

Many plans include a range of diagnostic (an examination by a dentist) and preventive (scaling, polishing) treatment services, generally covering a higher percentage of the associated costs. Such services can aid in the prevention of dental disease, identify trouble signs early and lead to less complex and costly treatment in the future. In considering a dental plan you may want to determine whether the annual cost of the premiums are preferable to simply budgeting for dental care.

There are many dental plan options available. Plan coverage is determined by you and/or your employer. The details of your plan are protected by thePersonal Information Protection Act (PIPA). While your dentist can help you understand your plan, they do not know the details of your plan and/or any changes that may occur.

It is your responsibility to understand what your plan covers. It is important to be aware of any financial limits and changes to your plan. See also: How can I find out what my dental plan covers?

Your dentist’s first obligation is to your health. If you have an issue with your mouth your dentist will present treatment options to meet your oral and overall health needs; your treatment plan is not based on your dental plan coverage. Your dentist can help you to get a pre-determination for treatment to understand what costs may be covered by your dental plan. See also: What is a pre-determination?

It is important to make your treatment decisions based on your health care needs, not based on what your dental plan covers. Speak to your dentist about his or her treatment recommendations and cost estimates along with any consequences in delaying or refusing treatment so you can make an informed choice for your health.

Dental plans are developed to offset some of the costs of treatment and generally include a selection of coverage; they are not developed based on your unique dental care needs, nor do they cover the full range of dental treatment services available.

Dental plans are selected by the plan purchaser, usually as part of a group benefits plan. Many plans will cover a range of diagnostic (examination) and preventive services (scaling, polishing). Such services are common to all patients and aid in the prevention of dental disease. Bear in mind that these plans may also have limits on the amount or frequency of services and treatment which is not based on what any individual may actually need. Additional treatment services will vary, as will the percentage of coverage patients receive for treatments covered by the plan.

Many dental plan carriers use the British Columbia Dental Association’s suggested fee guide as a reference to determine plan coverage. They choose treatment services and base the percentage of plan coverage on the fees outlined in the guide. They do not always use the most current guides; in some cases coverage is based on fees outlined in a previous year’s guide (going back a year or more). In addition, dental plan fee schedules may not include all the codes in the current BCDA guide.

Dentists are not required to follow the fees outlined in the suggested fee guide or the fees outline by dental plan providers. Any costs not covered by the plan are the patient’s responsibility. See also: What is the suggested fee guide?

Note: Professional dental organizations and dentists are not involved in any aspect of determining dental plan coverage.

The details of your plan are protected by the Personal Information Protection Act (PIPA). While your dentist can help you understand your plan, they do not know the details of your plan and/or any changes that may occur.

Employer plan: If your dental plan is part of an employee benefits package, ask your employer and/or human resource manager for a copy of the plan booklet. You should also speak to them about any questions related to your plan and/or any recommendations you may have for changes to your plan.

Individual plan: If you have and/or are purchasing a private dental plan ask the dental plan provider about available plans outlining what they will cover and for what you will be responsible. When choosing a plan look carefully at what you will be required to pay and what treatment will be covered. Ask your dental plan provider for a copy of the plan booklet.

Many plans also post information online. Ensure that you have the correct information to be able to access these details. Also ensure that you are aware if any changes to your plan occur prior to any dental appointments and/or treatment.

Dual coverage is when you are covered by two separate dental plans, such as your own plan and a spouse’s or a partner’s. It is likely that one plan provides the primary coverage while the second provides some additional support. This does not mean that you will always have 100 percent coverage. Dental plans generally cover a percentage of treatment and the patient is responsible for the remaining portion—the co-payment. This is particularly true if both you and your spouse/partner are covered by the same plan. See also: What is the dental plan co-payment?

What is covered will depend on your plan. Some dental plans may base the percentage of treatment covered on a specialist’s fee, others may only use general practitioners'(GP) fees while some may provide an enhanced level of coverage, such as 10 percent above a GP fee.

Review your plan booklet for details on your plan.

Most dental plans cover only a specific percentage of the cost of eligible dental treatment services (services included in the plan); the patient is responsible for the remainder along with any costs not covered by the plan. See also: What is the dental plan co-payment?
For example, many standard dental plans will cover 80 percent of basic/preventive dental services such as dental exams, X-rays, cleanings, fillings and root canals while coverage for other procedures such as crowns, bridges, veneers and dentures may be at 50 percent. Other plans may cover a higher or lower percentage of services; it is rare for any plan to cover 100 percent of every service. You should also be aware that most dental plans have a financial limit.

While your dentist can help you understand your plan coverage they are not experts on your plan. It is your responsibility to know the details of your plan. See also: How can I find out what my dental plan covers?

Your dental insurance coverage is based on the plan purchased by your employer for all employees which may or may not cover your unique oral health care needs. Your dentist may recommend that you have more or less frequent exams based on your unique dental health care needs and your general health status.

Ask your dentist if you have any questions. It is your responsibility to know what is covered in the plan as your dentist will not have this information. Speak with your dentists about your plan and your dental health needs so that you can understand your options and can make the best decisions for your own health.

Oral health is concerned with the entire mouth. During your dental examination, your dentist will inspect a number of important areas and functions of your mouth to identify and diagnose any problems. Your dentist will also check the condition and fit of any dental prosthesis (i.e. denture).

The health of the mouth is linked to the body. Your dentist is trained to identify early signs of disease in the mouth that could relate to other health issues such as cardiovascular disease and diabetes. The dental exam also plays a significant role in the early detection of oral cancer.

The early stages of dental disease do not have any symptoms. Dental disease is not reversible so prevention and early detection is extremely important. Your dentist is trained to catch early signs of conditions affecting your mouth to stop the progression of disease and prevent small problems from becoming larger ones.

The frequency of X-rays is determined on a case-by-case basis. Your dentist will work with you to review your oral health and assess the potential benefit of obtaining an X-ray to support your care. Discuss any concerns with your dentist.

The BCDA has produced a patient fact sheet to help you understand some of the things your dentist may look for during your exam. What is included in a dental exam or at each visit is not the same for everyone. Factors such as age, dental health status, level of general health, medication use and lifestyle choices may influence what is covered. Ask your dentist if you have any questions about your exam or what your dentist is looking for during your exam.

The frequency of your dental exam will depend on your unique dental health care needs. Many patients visit the dentist every six months. At a minimum you should visit the dentist at least once per year. How well you care for your teeth, whether you have any issues that need monitoring and the status of your general health can all influence the required frequency of your exams. The goal is to catch any trouble signs early.

Talk to your dentist about your oral health care needs and the frequency of your dental exam.

Prevention is the best way to maintain good dental health. Practice good dental habits at home: brush and floss daily; limit sugary drinks and snacks; don’t smoke; and visit your dentist for regular care including an examination. It is important to diagnose problems before they become more complex and costly. Dental disease is progressive and unlike a cold will not resolve itself. The cost of prevention is always far less than the cost of neglect.

While dentists are committed to delivering high quality dental care to their patients, dentistry cannot be guaranteed. To guarantee success is considered misleading and is contrary to the College of Dental Surgeons of BC’s Code of Ethics.

In order to provide an opinion related to dental care, a dentist must understand all the factors that are influencing a patient’s health. A crucial part of this is an examination of the mouth to identify and diagnose any dental disease. See also: Can I get an estimate for treatment before going to the dentist?

It is important that you feel comfortable in proceeding with any dental treatment. Your dentist is there to support your health and answer any questions you may have, including why they are recommending the treatment presented and/or any related to cost.

If you are concerned with any factors relating to a proposed treatment plan, you are welcome to seek a second opinion. It is important to understand that there will be an additional cost associated with this as the second dentist will need to conduct an examination and consult with you to develop treatment options.

Questions you might ask your dentist:

Why are they recommending the treatment options presented—what is/are the benefit/s to your oral/overall health?

Are there alternative treatment options available?

What are the implications of refusing or delaying treatment?

Is there anything you can change in your mouth care to prevent similar issues in the future?

What is required on my part to maintain the dental treatment recommended?

Treatment recommendations are developed by the dentist beginning with an examination of the mouth. The dentist will examine the patient, review their health history, and discuss any symptoms or concerns the patient may be experiencing. If your dentist identifies an issue in your mouth, they will discuss this with you along with their treatment recommendations.

Depending on the treatment options presented, further discussions related to materials, the extent of the care required, whether or not laboratory fees factor into care, etc. can influence the estimate. Your dentist can work with you to review treatment alternatives and provide a cost estimate for the treatment plan before proceeding. Note: A dentist can only provide an estimate. As with any medical-based procedure treatment planning can change over the course of treatment; this can have an influence on cost.

Dental specialists receive additional training in a particular field of dentistry. They bring a high level of expertise to treatment provided within their specialty. General practice dentists will refer patients where a specialist’s care is required.

Treatment provided within specialty fields is often highly technical and complex. It can involve the use of specialized equipment, materials required for treatment, additional staffing needs and ongoing education. All of these factors are considered by specialists when determining treatment costs.

Dental offices are similar to medical clinics and must adhere to strict regulatory standards in the interest of ensuring the highest level of patient safety and care. Dentists are essentially running mini hospitals and are responsible for a number of costs related to operating their dental office.

Specialized equipment; sterilization and safety protocols; hiring trained and licensed staff; and ongoing continuing education for the dental team all factor into the cost of dental care. External lab costs, materials used in treatment, the complexity of the treatment, practice location are also among considerations in determining costs.

Dentists have to consider such factors to determine the cost to deliver treatment for their office. Operating costs will vary between dental offices as well as provincially.

Copies of the suggested fee guide can be found in public libraries. Patients are reminded that this document is only a guide See also: What is the suggested fee guide?

The fee guide is very technical in nature; with over 1,400 codes covering various components of dental treatment the suggested guide can be difficult for patients to interpret. Patients are advised to discuss any questions related to their proposed treatment options or the cost of treatment with their dentist.

There is no requirement for dentists to charge the suggested fees outlined in the dental fee guides. Dentists determine costs for their office based on the factors influencing their individual practice. See also: How are dental fees determined?

While many dentists will follow a number of fees within the guide, there is no requirement to do so. Dental offices consider a number of variables when determining costs for their office. See also: How are dental fees determined?

The British Columbia Dental Association (BCDA) produces an annual suggested fee guide for dentists in BC. This document outlines over 1,400 dental codes and code descriptors related to specific elements of dental treatment. It also provides suggested fees that serve as a guide only.

Many dental plan carriers will base plan coverage on fees and codes within this guide. In some cases the coverage is based on previous year’s guides (going back a year or more). (Note: Dental plan providers do not work with the BCDA to develop the guide.)

The suggested fee guide serves as a guide only; dentists are not required to follow the guide or any fee schedule. Dentists may use it as a reference to determine a fee for their dental services, as a communication guide to outline treatment options to discuss with their patient and to assist in billing patients’ plans.