Question: I have a dental PPO plan though Anthem Blue Cross from my employer.  Even though I have had it for a few years this was the first time I really used it for anything more then my free cleaning.

About a month ago I had some dental work that was rather costly.  Now I get an additional billing from my dentist stated that the insurance did not pay out much for the full porcelain crown that I got.  However my dental plan says they will pay out half the cost for crowns.

Calling up the dental insurance company right away I was told that they do not cover out that ADA code but will cover up to the UCR rate for covered crowns on non covered crowns.  It really seemed like double talk to me.  A crown is a crown!  What do they mean ADA code?  Please help me understand.

Answer: ADA codes are the service code for each individual dental service. This code number does not change and it let everyone from the dental office, insurance company and claims department know what dental service you had done. Although wording can very the code dose not.

There are many ADA codes for crowns here is a sample

2740 Crown porcelain ceramic substrate
2783 Crown ¾ porcelain ceramic
2750 Crown-porcelain fused to high noble metal
2751 Crown-porcelain fused to predominantly base metal
2791 Crown-full cast predominantly base and
2810 Crown-3/4 cast metallic

There are more but I listed a few to show you that a crown is not just a crown. Under many PPO plans they may only provide benefits for a lower cost crown so when you get a higher cost crown they paid out only up to the UCR for the crown that they cover. This offers you some saving but now as much as if you would have chosen a covered crown.

One way to avoid having billing surprises such as these is to have your dental office submit claims as a quote only, to your insurance company prior to dental services being render.  That way you will know your cost ahead of time and then can decide if that is something you wish to continue with based on your budget.