Dental Articles - Waterdown

How Direct Billing Works at the Dentist

Direct billing means the dental office sends the claim to your insurer and the insurer pays the office its share, so you pay only your portion at the visit. The alternative is paying the whole bill yourself and waiting for your insurer to reimburse you. At Panacea Dental we accept most insurance plans and will always attempt to bill your insurer directly. This article explains what happens behind that sentence, and why the amount you pay is rarely zero.

What happens when we submit a claim

Dental offices in Canada send most claims electronically through CDAnet, the network run by the Canadian Dental Association that connects offices to insurers. The claim lists each procedure by its standard code, and the insurer usually replies within seconds with what it will pay. That is why we can tell you your share before you leave.

What you still pay, and why

Even with direct billing, most patients pay something. The usual reasons:

• Co-insurance. A plan paying 80 percent for basic services leaves 20 percent to you.
• The deductible, if your plan has one and it has not been met this year.
• The annual maximum. Once it is used up, the plan pays nothing further until it resets. See when dental insurance resets.
• Frequency limits. A cleaning or examination done sooner than your plan allows is not covered.
• The fee guide year. Some plans reimburse against an older year of the Ontario Dental Association fee guide, leaving a gap even when the fee follows the current guide. Our dental costs and fees page explains this.

When direct billing is not possible

Occasionally it cannot be done. Some employer plans are set up to pay only the member, not the office. Some claims need a written predetermination before the insurer will commit. And now and then an insurer system is simply down. In those cases we give you a detailed receipt with every procedure code so you can claim yourself, usually through the insurer's app.

What to bring to your first visit

• The name of the insurance company, and your group or policy number.
• Your member or certificate number, which is often on a card or in the insurer's app.
• The plan member's name and date of birth, if the plan is through a spouse or parent.
• The same details for any second plan you are covered by.

With that, our front desk can check your coverage before treatment starts.

Covered by two plans

Many families have coverage through both partners' jobs. The claim goes to the primary plan first, and the secondary plan can then pay some or all of what is left, which is called coordination of benefits. The general rules in Canada are:

• For an adult, your own workplace plan is primary and your spouse's is secondary.
• For children covered by both parents, the plan of the parent whose birthday falls earlier in the calendar year is usually primary. Separated or divorced parents can have different rules.

Tell us about both plans and we will submit to each in the right order. Students are often covered twice too, by their own student plan and a parent's plan.

Predeterminations for larger treatment

For anything beyond routine care, such as a crown, bridge or implant, we can send the treatment plan to your insurer before starting. The insurer replies in writing with exactly what it will pay, so you know your own share before you commit. It adds a little time and removes the guessing.

The Canadian Dental Care Plan

If you are covered by the Canadian Dental Care Plan, we bill the plan directly too. You pay any co-payment that applies to your income level, and any difference between the CDCP fee and the practice fee, which we will tell you before treatment. Bring your CDCP member card or client number.

Paying your share

Any balance the plan does not cover is due at the time of the visit. We accept Visa, MasterCard, American Express, debit and cheque.

Panacea Dental is at 105 Clappison Ave #103 in Waterdown, open Monday to Friday from 10:00 am to 7:00 pm and Saturday from 10:00 am to 3:00 pm. We are accepting new patients. Call 289-408-5100 or book online.

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