Collinsville Family Dentistry 1310 W. Main St., COLLINSVILLE, OKLAHOMA
Insurance Information

Insurance Provider For:

  • Guardian
  • Met Life PPO
  • Health Choice
  • Delta Dental PPO
  • Delta Dental Direct
  • Aetna PPO
  • Aetna Access
  • Cigna DPPO
  • Blue Cross Blue Shield PPO
  • Careington

People often want to know if we accept certain insurances. We are "in network" with several insurances, some of those are listed above, but we also work with any plan for which a patient has out of network benefits, and can choose which providers they wish to see. (usually known a PPO plans). We do not accept Medicare, Medicaid or HMO plans at this time. If you come see us and you are "in network" that means we have to match your insurance ALLOWABLE FEE. If you come see us and you are "out of network" it means that IF there is a difference between Our fee and the ALLOWABLE fee set bu your insurance, you are responsible for the diference

Understanding Your Insurance:

Why Doesn't My Insurance Pay For This? -- per American Dental Association Information

"Employers offer dental benefits to help employees pay for a portion of the cost of their dental care. Dental plans are designed to share in the cost of your dental care, not to completely pay for those costs. Almost all dental benefit plans are the result of a contract between the plan sponsor (usually an employer or a union) and the third-party payer (usually an insurance company.) The amount your plan pays is determined by the agreement negotiated by your employer with the insurer. Your dental coverage is determined not by your dental needs -- but by how much your employer contributes to the plan."

Commonly Misunderstood Features of a Dental Plan:

UCR (Usual, Customary and Reasonable)
Usual, customary and reasonable charges (UCR) are the maximum amounts that will be covered by the Plan for eligible services. The plan pays an established percentage of the dentist's fee or pays the plan sponsor's "Customary" or "reasonable" fee limit, whichever is less. Although these limits are called "customary," they may or may not reflect the fees that area dentists charge. Exceeding these plan's customary fee, however, does not mean your dentist has overcharged for the procedure. Why? There are no regulations as to how insurance companies determine reimbursement levels, resulting in wide fluctuation. In addition, insurance companies are not required to disclose how they determine "usual, customary and reasonable" charges.

Annual Maximums
Most dental programs have an annual dollar maximum. This is the maximum dollar amount a dental plan will pay towards the cost of dental care within a specific benefit period. The plan purchaser / employer makes the final decision on "maximum levels" of reimbursement through the contract with the insurance company. The patient is usually responsible for paying costs above the annual maximum. Even though the cost of dental care has significantly increased over the years, the maximum levels of insurance reimbursements have remained the same since the late 1960s.Your employer may want to research plans that offer higher anual maximums.

Preferred Providers
The plan may want you to choose dental care from a list of their preferred providers. This is a term that often is applied to dentists who have a contract with thedental benefit plan. Whether or not you chose to receive dental care from this defined group can affect the level of reimbursement.

Pre-Existing Conditions
Just like medical insurance, a dental plan may not cover conditions that existed before the patient enrolled in the plan. This includes plans that have a "missing tooth" exclusion. Benefits will not be paid for replacing a tooth that was missing prior to the effective date of coverage. Even though your plan may not cover certain conditions, treatment may still be necessary.

Treatment Exclusions
A dental plan may not cover certain procedures or preventative treatments. Some plans exclude certain dental treatments such as sealants, implants, pre-existing conditions, adult orthodontics, specialist referals and other dental needs. Some also exclude coverage if the procedure was provided by a dentist who is a family member. This does not mean that these treatments are unnecessary. Patients need to be aware of the exclusions and limitations in their dental plans but should not let those factors determine their treatmen decisions. Your dentist can help you decide what type of treatment is best for you.

Plan Frequency Limitations
Certain procedures may simply not be covered as often as necessary for optimal oral health. A common example might be a plan that pays for tooth cleaning only twice a year even though a particular patient may require cleaning every three months. Other plans, for instance, will only pay sealants once in a lifetime, when generally sealants only last between 5 and 10 years. Limitations may vary depending on the contract purchased. Limitations in coverage are the result of the financial commitment the plan sponsor has agreed to make and the benefits the third-party payer will offer for that commitment.

Not Dentally Necessary
The plan provides benefits for those services and materials that they consider to be dentally necessary and meet generally accepted standards of care. Based on the information your dentist submits, the service may not appear to meet plan criteria and no benefit may be allowed. You or your dentist can appeal the benefit decision by submitting relevant information. The claim, along with the submitted information should be reviewed by the plan's dental consultant.

Cost Control Measures
To keep the premium costs down, insurance carriers will incorporate cost-control measures into the plan design. By incorporating cost control measures during the claims adjudication process, many times benefits are reduced or not paid at all. Some of themore common cost control measures are:

  • Bundling -- This is the systematic combining of distinct dental procedures by third-party payers that result in a reduced benefit for the patient / beneficiary. A common example of bundling is when bitewing and periapical radiographs are combined and paid as a full mouth series of X-rays. The full mouth series is then subject to the plan's limitation of allowing benefits, usually, once every five years for these X-rays.
  • Downcoding -- This is a practice of third-party payers in which the benefit code has been changed to a less complex and / or lower cost procedure than was reported except where delineated in contract agreements.

Least Expensive Alternative Treatment
The dental plan may only allow benefits for the least expensive treatment for a condition. For example, the dentist may recommend a resin composite filling ona posterior tooth, but the insurance may only offer reimbursement for an amalgam filling. As is the case of exclusions, patient should base treatment decisions on their dental needs, not on their dental benfit coverages. In many instances, the least expensive alternative is not always the best option.

Direct Reimbursement
Direct Reimbursement is a self-funded dental plan that reimburses an individual based on a percentage of dollars spent for dental care, not on the type of treatment provided; it also allows the patient to seek treatment from the dentist of their choice. Unlike some forms of dental benefits, direct reimbursement allows patients to plan treatment with their dentists alone, with no third party interference through exclusions (except cosmetic) or plan frequency limitations ontreatment. There are no predetermination requirements, no pre-existing conditions, no UCR, and typically no deductibles. In addition, there are no bundling or downcoding or least expensive alternative treatment clauses. Please contact the ADA at 800-232-1890 or for more information on Direct Reimbursement.

Dr. Melissa Bowler, DDS -- (918) 371-3774