Insurance At West Texas Pediatric Dentistry In Midland TX

Preventive Care: Most dental plans cover 100% of preventive dental care in Midland TX, including routine checkups, cleanings, and X-rays. Some plans may limit the number of cleanings covered per year (usually two).

Basic Procedures: Dental insurance typically covers a percentage of fillings, simple extractions, and treatments for gum disease, often around 80%, after you've paid your deductible.

Major Procedures: Coverage for major procedures like crowns, bridges, dentures, root canals, and oral surgery is usually lower, often around 50%, and may have a longer waiting period. Some plans may classify root canals as basic procedures.

Out Of Network Dental Care In Midland TX

Specialization or Specific Needs:

"This dentist specializes in pediatric dentistry, which is important for my child’s dental needs."
"My child has a specific condition that this out-of-network dentist has significant experience treating."

Potential Cost Trade-off for Quality/Preference:

"I understand that going out of network might mean slightly higher out-of-pocket costs, but for me, the peace of mind and confidence in the quality of care are worth the potential difference."

You have the Right to Choose Your Provider (within limits):

"While my insurance encourages in-network care to manage costs, I still have the option to choose an out-of-network provider if I believe it's in my child’s best interest for the quality of care."

Insurance And Office Fees:

Our Office Fees:

Our office fees are what we charge for the quality dental services we provide. These fees are based on the cost of running our practice, including the materials we use, the technology we invest in, our staff's expertise and time, and the quality of kids dental care we strive to deliver in Midland and the West Texas area
These fees are consistent for all of our patients who don't have specific contracted rates through their insurance.

UCR Fees (Usual, Customary, and Reasonable):

Your dental insurance company has its own set of fees they consider 'Usual, Customary, and Reasonable' (UCR) or allowable fees for dental procedures in our geographic area.
UCR fees are essentially the maximum amount they are willing to pay for a particular service.
Insurance companies determine these UCR fees based on data they collect about what dentists in a specific region typically charge. However, the exact method they use to calculate these fees is often proprietary and can vary significantly between insurance companies.
It's important to understand that the UCR fee is not necessarily what all dentists in the area charge, nor is it a direct reflection of an individual dentist's costs or quality of care.

What’s the difference?:

The key factor to understand is that our office fees and your insurance company's UCR fees are often different.
Our fees might be higher or lower than their UCR for a specific procedure.

How does Insurance Reimbursement Work with UCR?

Based on what plan you signed up for, your insurance policy will typically pay a percentage of the UCR fee for covered services, after you've met your deductible and before you reach your annual maximum.
For example, your plan might cover 80% of the UCR for a filling. If the UCR for that filling is $100, they will pay $80.

Potential Out-of-Pocket Costs:

If our office fee is higher than the insurance company's UCR, you will be responsible for the difference, in addition to any co-insurance or unmet deductible.
Example: "Let's say our fee for the filling is $120, and the UCR is $100. If your insurance pays 80% of the UCR ($80), you would be responsible for the remaining $40 ($120 - $80), plus any deductible or co-insurance."
Conversely, if our fee is lower than the UCR, your insurance will still base its payment on their UCR, and your out-of-pocket cost might be lower.

Potential "Balance Billing":

We might 'balance bill' you for the difference between our actual charge and what your insurance pays.

Deductibles and Annual Maximums:

Any out-of-network costs also go towards your annual deductible, and the total amount your insurance will pay in a year is still subject to your annual maximum."

Consider Pre-Treatment Estimates:

To get a better idea of your out-of-pocket costs, ask our coordinator to submit a pre-treatment estimate to your insurance company. This will give you an idea of their U&C/R&C fee and what your insurance is likely to cover.

Our office has no control over UCR:

Please know that our office has no control over how your insurance company determines its UCR fees. This is a contract between you (or your employer) and the insurance company.

Solutions and Transparency:

We will always do our best to provide you with a closest accurate estimate of your out-of-pocket costs before treatment.
We can submit a pre-treatment estimate to your insurance company to get a more precise idea of their UCR and your expected coverage.
We are happy to help you understand your insurance benefits as much as possible, but the most accurate information about your coverage and UCR fees will come directly from your insurance provider.
If you have questions about why there's a difference between our fees and your insurance's reimbursement, we encourage you to contact your insurance company directly for clarification on their UCR calculations.

Key Takeaways :

Our fees are based on our practice costs and quality of care.
The insurance company's UCR fees are their determined "allowable" amounts.
Insurance pays a percentage of the UCR, not necessarily their entire allowable amount / our full fees.
You may be responsible for the difference between our office fees and the insurance payment.

What if you are in network but are receiving a non covered service?

We do bill our in-network patients our standard office fees for services that their dental insurance plan explicitly does not cover.

Non-Covered Services: If a dental service is specifically listed as "not covered" or "excluded" in your child’s dental insurance plan documents, our contract with the insurance company generally allows us to bill our usual and customary (U&C) office fees for that service. The in-network contract primarily dictates the fees for covered services.

We Verify Patient Benefits:

before providing the non-covered service. This will confirm that the service is indeed excluded from your coverage
Before providing the non-covered service, we will have a clear and open discussion with you, the parent.
We provide a good faith estimate of our office fee for the service.
We obtain your explicit consent to proceed with the treatment, acknowledging your financial responsibility for the full fee.
We will have you sign a financial responsibility agreement or a consent form for non-covered services.

Distinguishing "Non-Covered" from Other Reasons for Non-Payment:

Non-covered means the service is explicitly excluded by the plan.
Frequency limitations, waiting periods, deductibles, and annual maximums are reasons why a covered service might not be paid, but the service itself isn't "non-covered." We generally bill you the remaining balance after the insurance processes these.

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OFFICE HOURS

Monday
8:00am - 4:00pm

Tuesday
8:00am - 4:00pm

Wednesday
8:00am - 4:00pm

Thursday
8:00am - 4:00pm

Friday
8:00am - 1:00pm

Saturday & Sunday
Closed

West Texas Pediatric Dentistry

3306 Andrews Hwy
Midland, TX 79703

(432) 242-5747