Question: I have a dental PPO plan I get though my job.  What I do not understand is how my dental insurance states my coverages are one thing but when a claim is filed the numbers do not add up.  For an example, not that long ago I had a large filling and a crown put on.  The filling coverages where to be at 80% paid.  Which it was so that was fine

However the crown I got cost $1000.00 and my plan said that it paid out 50% for the cost of a crown.  Straight forward math right I should only have to pay $500.00 which was my co-payment of 50%.   I then get the billing from the dental office stating the insurance company only paid out only $450.00 so my cost is $550.00 now it is only $50.00 more but this happens quite a lot. What should I do about this?

Answer:  In general PPO plans pay out by percentage in your case 80% for basic services such as fillings and 50% for major services such as crowns.  But it dose not just stop there.  Normally they will state that the percentage paid out is up to UCR (Usual, Customary, and Reasonable) There for if the dentist you are going to is above the UCR rate for the company you will have an additional charge.

Also some PPO plans will have two sets of coverage one for network dentist and another for out side network dentist. Out side network dentist normally will have less benefits then inside network providers.

As to why you are paying more, I could not say which is the case for you. That will be something I would advise you call your plan’s member services for. They can go over your benefits and directly answer what is effecting your cost on claims.

However here is a tip you may want to keep in mind. Prior to having any dental services started, have your dental office submit to your insurance company as a quote only. That way you will know your true cost for any needed dental care without having to worry about additional cost.