Understanding Dental Insurance

For many people, the new year means that your benefit plan has reset, or a new insurance plan has begun. Understanding what your insurance company covers can be difficult because dental offices and insurance companies speak in code, literally.

Simon Pong Dentistry wants to help clarify this confusion for our patients. In this blog, we will break down some of the frequently used codes and coverage-related questions to help you better understand what your insurance company may or may not cover.

What the difference between basic coverage and major coverage?

Basic coverage refers to procedures including:

• Exams
• Checkups
• Cleanings (scaling)
• X-rays
• Root canals
• Fluoride treatment
• Teeth polishing
• Wisdom tooth extractions

Major coverage refers to procedures including:

• Crowns (caps)
• Bridge work
• Dentures
• Implants

Orthodontic services are completely separate from both basic and major coverage.

Each insurance company will allot a dollar maximum to basic coverage. For example, $2,000 per year at 90% for basic coverage, or $1,500 per year at 50% for major coverage.

How often are dental cleanings covered?

Most insurance plans cover cleanings twice per year. Some plans do offer more coverage — we recommend checking your specific plan for the details because many patients visit their hygienist every three to four months.

What are the dental cleaning codes?

There are two important codes that are used when you see your Dental Hygienist. An exam or checkup is coded as 01202. This code is covered every six or nine months depending on your insurance coverage.

The second important code allows you to have your cleaning done more than once or twice a year, this is the scaling code — code 11112,11113, or 11114. Each insurance company will allot a certain number of scaling units. If you are seeing your Dental Hygienist on a regular basis, then a typical visit will use between two and four units of scaling per appointment. If you have 16 units available per year, then this should cover you for four cleanings in a calendar year.

How many dental x-rays are covered by insurance each year?

X-rays are considered basic treatment, but some x-rays are covered more often than others. The x-ray to be aware of in regards to frequency of coverage is the full Panorex. Most insurance companies cover this type of x-ray every two to five years.

Checkup x-rays are covered more often. If needed, most insurance companies will cover this type of x-ray every year.

How do I know if my insurance covers getting a crown or braces?

If you require major treatment or orthodontic treatment, we will send a treatment plan to your insurance company with the necessary x-rays to get approval before treatment is started. There is no cost to the patient for us to submit a treatment plan on your behalf. Our goal is to provide you with all the information and treatment options available to you.  

It may take up to four weeks for the insurance company to respond to our request, and they will email you the details directly — for privacy reasons, the dental office does not receive this information.

Dental insurance coverage can be confusing, but we are here to help. For more dental insurance related questions, contact the office of Dr. Simon Pong. Our team will be happy to assist you.