Metal Mouth Message Board

rsprouse

I beg to differ on the pre-approval issue. Depending on the insurance company, some providers are "in-network" and some aren't. If the pre-approval is for an in-network, and the perio or other provider is out-of-network, the pre-approval is worthless.

Are you a dentist or something?

Regarding pre-approval on an SRP, it is a procedure only covered once every 24 months (generally) for most dental insurance providers. If a patient of a general dentist has not been a patient of record for at least 24 months then it is in the best interest for the office to get pre-approval. Patients don't like unexpected charges and office's don't like upset patients. This is true regardless if a dentist is "in-network" or not.

You are correct, if we are talking about a longstanding patient and the office is sure that it will be covered then it does not need pre-approval. And even if the office is "out-of-network", if they are taking the time to get pre-approval then they will most likely be collecting some form of payment from the insurance company, albeit less than the charge for "in-network". Of course there are plenty of clinicians out there that do not accept insurance and the patient may be responsible for full payment and will be reimbursed by the insurance company directly.

Nope I am not a dentist, but I will officially be one in about a year (knock on wood). As always, YMMV as every insurance plan is different and rules and regulations vary from state to state.

Guess what? i did ask my ortho if i need a deep cleaning?? he checked and said, "nah, u just need some whitening and cleaning after the braces are done", and i feel a big release now. Again, thanks for all the replies. = )

YMMV=???

Your point is very well taken that insurance regulations vary by state and by company. I've never been to dental school in my life, but as a social worker I've dealt with insurance companies to advocate for benefits for my clients and it concerned me when you posted about the "clinical need existing" as if to imply that the patient can simply go elsewhere once there is a pre-approval from their insurance company.

In many, but not all, insurance companies, pre-approvals are tied to the provider, particularly HMO.

I also wonder where you got your information about needing pre-approval if not a patient of 24 months, versus patient of 24 months. I agree there is a limit on frequency of having the procedure, but most policies I am familiar with look at length of time policy has been held, not whether you have been a patient on record for a certain period of time.

YMMV - Your Method/Mileage May Vary

The 24 month comment is simply that SRP's are covered no more frequently than every 2 years. If a patient has been going to a single clinician for more than 2 years then the clinician can pretty much imply that the patient has not had the procedure elsewhere and there insurance has not been previously billed. If the patient has potentially had their insurance billed for an SRP previously in the past 24 months then they may have a different opinion on the procedure if it costs them nothing or $250/quadrant. But, there is no harm/ding/whatever for getting pre-approval on a procedure with your dental insurance.

Dental insurance in thankfully VERY different than medical insurance. I like to call it a "Dental Discount", but it is marketed as traditional insurance. The HMO likeness does not exist, thus our differing of opinions.

Best,
Rory

Somewhere there is a disconnect. Both Delta Dental and Concordia have policies where you get maximum (or any) benefit only by going to their providers. Indeed, one of Concordia's programs is called "DHMO Concordia Plus."