Significance of the Missing Tooth Clause in Dental Insurance

00:01 – Introduction

Hi, this is Amber Darst, Solutions Manager here at MOS and today I’ll be discussing the importance of understanding the missing tooth clause and submitting dental predeterminations. Understanding this can save you from unexpected expenses and help you make informed decisions about your dental treatments.

00:20 What is the Missing Tooth Clause?

Did you know that over 50% of dental plans include a missing tooth clause? This clause can be confusing for both patients and dental teams alike. Essentially, it means that if you’ve lost a tooth before enrolling in your dental plan, the insurance company may deny coverage for any tooth replacement procedures. This applies even if the tooth was congenitally missing.

Picture this scenario. The dental plan states that they cover 50% of the cost of a tooth replacement procedure and the patient pays their balance. However, if the missing tooth clause is in effect, the patient will have to bear the entire cost of the replacement, be it a bridge, crown, denture or implant, which can be quite expensive. Additionally, keep an eye out for waiting periods, as some dental policies require waiting periods before they cover tooth replacement cost. Waiting periods can range from a few months to several years, depending on the insurance company.

01:19 How Predeterminations Can Help

Now let’s move on to predeterminations.

To avoid surprises and plan better for your dental treatments, obtaining a predetermination can be immensely helpful. Predeterminations are estimates of what the insurance company will cover for specific procedures. They’re recommended for costly treatments such as extractions, crowns, implants, and more.The ADA defines predeterminations as an estimate of who pays what for the service.By obtaining a predetermination, patients can understand their coverage better, including the coinsurance deductible and policy maximum they might need to pay out of pocket.

Having a treatment plan in hand, your dental office can request the insurance company to review it. If a procedure is denied, you have the option to appeal the decision with proper documentation. Some insurance companies may even waive the missing tooth clause if the tooth was extracted within a specific timeframe before the proposed replacement date.

02:26 Dental Insurance Verification Services to Understand Patient Coverage

Understanding the complexities of dental insurance can be overwhelming. Dental insurance verification services offered by dental billing companies can be a game changer. These services help your front office gain clarity on patient coverage before any treatment is provided. You will receive comprehensive reports on the plan details, coverage, and exclusions such as the missing tooth clause. With this information, you can educate patients about their specific insurance plans, helping them make informed decisions and fostering trust in your dental practice. Moreover, accurate billing ensures that you receive proper insurance payments without any losses. Dental insurance plans can be intricate, but with knowledge of the missing tooth clause and the use of predeterminations, along with dental insurance verification services, you can navigate the system with confidence.

And that’s all on this.

Thanks for listening in.