Dental insurance plans offer coverage for specific dental procedures. According to the National Association of Dental Plans, as many as 77% of Americans possess dental benefits. Some plans cover a percentage of the cost for basic services, while others contribute to the cost of both basic and major dental work. Dental benefits are intricate, varying among plans and insurance companies, and they may change annually. Many dental plans also include exclusions, such as the missing tooth clause. Dentists can collaborate with their dental billing company to assist patients in understanding the details of their coverage and maximizing their benefits.
Key Points About the Missing Tooth Clause
Like medical insurance, a dental plan may not cover a condition that existed before the person enrolled. The missing tooth clause in dental insurance is akin to this pre-existing condition exclusion in medical insurance but is more specific. Over 50% of dental plans include this clause.
Both patients and their providers need to understand the policies, terms, and conditions of the missing tooth clause. This clause often confuses the dental team because the insurance plan may state that the prosthesis is covered at 50%, with the patient responsible for the remaining balance.
A missing tooth clause is a contractual provision in a dental insurance plan where the insurance company can deny coverage for the cost of the tooth replacement procedure if the tooth was lost, extracted, or removed before the patient’s coverage takes effect. This clause may also apply to a congenitally missing tooth. Consequently, the patient will have to pay entirely out of pocket for the tooth replacement, whether it is a bridge, crown, fixed partial denture, removable partial denture, or implant, which can be expensive.
Another important aspect to consider in a dental policy is the waiting period. Key points include:
- In some cases, the insurance policy will cover tooth replacement costs after the waiting period has ended.
- If the missing tooth clause includes a waiting period, the plan will not cover a tooth replacement if the tooth was lost during this waiting period.
- Waiting periods vary among insurance companies and usually range from a few months to one year.
However, some policies have waiting periods that extend up to five years. Not all dental policies include a missing tooth clause. For example, Delta Dental does not have a Missing Tooth Exclusion and covers tooth replacement procedures for members who lost or had a tooth extracted before obtaining dental coverage with Delta Dental.
Certain Cigna PPO plans include a Missing Tooth Clause. Cigna states: “If a bridge replaces teeth that were missing prior to the date the person’s coverage became effective and also teeth that are extracted after the person’s effective date, benefits are payable only for the pontics replacing those teeth which are extracted while the person was insured under this plan.”
Patients should be advised to read the fine print of their dental plans and be aware of what is covered and what is not, including the missing tooth clause. If the insurance policy includes a missing tooth clause and the patient still wants the treatments, a predetermination can be set up.
Understanding the Role of Predeterminations
Some plans recommend obtaining predeterminations for procedures exceeding a specific dollar amount. Such procedures include extractions, crowns, onlays, veneers, fixed bridgework, implants, or periodontal treatments. The American Dental Association defines a predetermination as “an estimate of who pays what for the service.” Predeterminations, or pre-treatment estimates of patient eligibility for coverage, are a useful strategy for dental offices when working with patients to obtain their consent for desired treatment plans. This helps patients understand what they will need to pay out of pocket after any coinsurance, deductible, and policy maximum. With a predetermination, patients will have the information required to make an informed financial decision about their treatment.
Once the diagnosis is complete, you should provide the patient with a treatment plan, which will help them determine how to pay for their treatment. The insurance company can be asked to review that treatment plan. Your office can send an appeal along with the proper documentation to overturn the original decision. According to Riverside Dental Care insurance companies may waive the missing tooth clause if the tooth was extracted within three years of the proposed replacement date.
What Dental Insurance Verification Can Reveal?
If patients do not understand or overlook a missing tooth clause, they may end up paying much more than expected. Dental verification, which is the first step in dental billing, can resolve this challenge. Dental insurance verification services provided by dental billing companies can help your front office clearly understand the details of patient coverage before treatment is provided. This includes information on the type of plan, coverage, payable benefits, plan exclusions such as the missing tooth clause, and much more. With the reports provided by your dental billing company, you can educate patients about the specific details of their insurance plan and help them make informed decisions, which will build their trust in your dental practice. It will also ensure proper billing to avoid loss in insurance payments.
