Common Insurance Terminology

Procedure Codes

The Ontario Dental Association (ODA) has designated a specific procedure code to each individual dental service. Procedure codes are standard throughout Ontario; dental offices are not permitted to change or alter procedure codes.

Fee Schedules

There are approximately 5,000 different dental procedure codes. The ODA publishes an annual Fee Guide, which is a reference list of all the procedure codes and their associated fees.

Each procedure code has a suggested fee assigned, which may or may not change for the following year. The suggested fees serve as a reference and a standard, but there a large variance across the province and country.

Insurance companies are free to formulate their own dental fee schedules. They are not bound by any governing agency to maintain current or consistent fees. Insurance companies set different fee schedules for the different policies/plans that they manage. The level of benefits provided by each  dental plan is determined by the premium amount paid by the employer holding the plan. This is a balancing act, taking into account the employer's  budget available for employee benefits, and which benefits the employer chooses to offer within the limits of its budget.   

Co-payment

Most dental plans do not cover the full amount of dental fees. They will normally pay 80% for basic services and 50% for other, more major services. The percentage not covered by the dental plan is known as the co-payment.

Many dental patients believe that the dentist can waive the co-payment so the patient doesn’t have to pay. This is illegal and forbidden. Dentists are legally obligated to collect the co-payment. Dentists who do not collect the co-payment face very serious consequences, including losing their license to practice. The Royal College of Dental Surgeons of Ontario, dentistry’s regulatory body, is responsible for ensuring dentists adhere to this requirement.   

Fee Schedule Difference

Even if there is no co-payment, there may still be a portion not covered by the insurance company, due to a fee schedule difference.

The ODA Fee Guide is a reference of suggested fees for dental services that is updated annually by the Ontario Dental Association. While most dental plans base their reimbursement on the current ODA Fee Schedule, some dental plans will reimburse based on fees set from past versions of the ODA Fee Guide. This is one of many possible methods for an employer to control their employee benefits costs.  In these cases, even if the specific procedure is covered 100%; the insurance carrier will reimburse 100%, but based on the Fee Schedule from the previous year specified in the dental plan.  

Frequency Limitations

Many dental services have frequency limitations. This means that these services are “covered” but must be spaced a certain number of months or years apart. These limitations are not based on your dental needs, but determined solely upon your policy’s premium level.   

Plan Maximums

Most insurance companies limit the total amount of coverage available by placing a dollar maximum on the total amount of funds they will pay out for each insured member. This is called the plan maximum. This is an important factor because even if you have “coverage” under your policy for dental treatment, if you have no available funds for the remainder of the policy year, your policy will not pay out.

Deductibles

Similar to your car insurance, some dental policies have deductibles. This is the amount that the dental policy will take off the first processed claim of each policy year for each covered person before they will make payment for services. To illustrate, if the total eligible claim is for $100 and the deductible is $25, the insurance company will make their payment based on $75.00. Some insurance policies combine a deductible, a co-payment, and a lower fee schedule (which will result in a fee schedule difference) to limit the amount they will have to pay.

Service Dates

Dental offices are legally required to bill dental procedures on the date they were performed. This means that even if dental work is pre-approved, the insurance coverage must be in effect on the date of service.

How Can Scarborough Dental Care Help?   

Understanding Your Benefits

At Scarborough Dental Care, we strive to make your entire appointment as easy and seamless as possible.

If you need help understanding your benefits or are unsure of what services are covered by your plan, we'll contact your insurance company for a complimentary benefits check and explain it to you as clearly as possible. Please note, due to privacy legislation limitations, some insurance companies will not release insurance information to a dental office without the patient present to give verbal authorization. In addition, insurance companies vary in the amount of information they will release to a dental office.  

Reimbursement for Dental Services

Reimbursement from your insurance provider is usually very simple. We are happy to submit your dental claims directly to your insurance provider for you. As most insurance claims are submitted electronically, most  patients are reimbursed within 24 hours, with almost all patients  reimbursed within one week.

If you have two insurance policies (ie. dual insurance), we’ll submit your first claim electronically. If your second insurance carrier has the capability for dual electronic submission, this will be done automatically as well. If not, we can give you a printed claim form to submit to your second insurance carrier,  or we can submit it for you by mail once we receive the claim response from your first insurance, which is usually instantaneous. You are responsible for any amounts not covered by your insurer. We would be happy to explain this process to you in further detail if you wish. 

Your Dental Benefits – Between You and Your Insurer

It is important to remember that your benefits are a contract between you and your insurer. If your benefits change, our office will not be contacted by your insurer to inform us of any changes to your plan due to national privacy legislation. Therefore, it is your responsibility to inform us of any changes to your insurance benefits. We will be happy to assist you in obtaining and/or understanding these changes. 

It’s always good to be knowledgeable and informed about your entire insurance benefits package. Most insurance companies have a call centre specifically designed to handle enquiries from patients, and many insurers have an online inquiry portal as well. What's more, we’re just a phone call away!