After you satisfy the deductible, the plan will reimburse you for a percentage of your eligible expenses and you will pay the balance. The percentage you pay is called your coinsurance percentage, and may be higher than for in-network services. You must complete claim forms and file claims with the dental plan to receive payment of benefits. The plan will not cover any charges above the allowable amount.

You may not need to file a claim form when you see in-network providers. When you do need to file a claim form, as you need to do in most cases when you go out-of-network, your dentist may handle your expense in one of two ways. Most dentists require you to pay the bill right away. In this case, get a receipt and file it with a claim form to be reimbursed. If the expense is covered, you will be reimbursed for part of the bill. To file a claim, follow the instructions on the claim form. If you have more than one health or dental insurance plan and have received an Explanation of Benefits (EOB) form from another plan, be sure to include a copy with your claim. Sometimes dentists are willing to wait for payment. In this case, you or your dentist will file the receipt and completed claim form with your dental health care company. The dental health care company will pay the dentist for the part of your expense the plan will cover. The dentist will then bill you for the part the plan did not pay.

If you need dental care while traveling, call member services for your dental plan at the number on your ID card. Member services can refer you to an in-network dentist. In a dental emergency such as an accident in which you lose teeth or extreme dental pain, contact member services if you are able and the dental plan can help you decide where to go for care. However, even if you are unable to contact member services, get the care you need. Even if you need to go out-of-network, your plan may cover emergency care at in-network benefit levels as long as you follow the plan rules.

A deductible may only apply, or may be higher, when you obtain care out-of-network. A deductible is the part of eligible expenses you must pay before the plan begins to pay a percentage of your eligible expenses.

Yes. Some of your expenses will not count toward your deductible. For example, amounts your dentist charges above the plan’s allowable amount for a given service will not count toward your deductible.

Coinsurance may only apply to out-of-network care. After you satisfy the deductible, the plan will reimburse you for a percentage of your eligible expenses for out-of-network care and you will pay the balance. The percentage you pay is called your coinsurance percentage.

If your plan has copayments, the copayment generally applies to in-network care. With this type of plan, when you obtain care from an in-network provider, you pay only a fixed amount at the time you receive services. That amount is called your copayment.

Predetermination of benefits is the process by which a dental care company reviews the proposed treatment and tells you and your dentist how benefits may be paid. It's a good idea to obtain a predetermination of benefits before expensive services are performed. Have your dentist complete a form showing the proposed treatment and submit it to your dental care company. The dental care company will send your dentist an explanation of what benefits would be covered and what you would have to pay out of your pocket. You can then discuss your treatment options with your dentist.

The terms "allowable amount," "U&C amount" or "R&C amount" vary by plan but refer to the same thing. The allowable, usual and customary or reasonable and customary amount is the amount usually charged for a given service by most providers in your area. This amount is determined by your dental care plan. If your dentist charges you more than this amount, you will not only be responsible for your deductible and coinsurance, but also for the entire difference between the U&C amount and the amount your provider charged. This concept only applies for out-of-network care, because PPO dentists have agreed to accept negotiated fees, which are by definition allowable amounts. For example, suppose you receive a service for which the "U&C amount" is $100 but your dentist charges you $110. The dental care company will multiply the percentage the plan pays for that service by $100. So even if the service were covered at 100%, you would pay the $10 difference ($110 charge minus $100 U&C).

Covered services are services covered by the plan. No dental plan covers everything. If you obtain services that are not covered services, you pay the full cost for those services.

An out-of-pocket maximum is the most you would have to pay “out of your own pocket” for eligible expenses. Not all plans have an out-of-pocket maximum. Check your Benefits Summary for details. With a plan that has an out-of-pocket maximum, once you reach the out-of-pocket maximum for a given year, the plan would pay all eligible expenses for covered services until any lifetime maximum benefit is reached. Not all expenses count toward an out-of-pocket maximum. Expenses for services that are not covered under the plan and amounts over any allowable amount limit would not count toward your out-of-pocket maximum.

A lifetime maximum is the most that will be paid by the plan for covered services for a given plan member. Not all plans apply a lifetime maximum, and some plans have different lifetime maximums for different services or for in-network and out-of-network services. Once you reach the lifetime maximum, you pay all expenses over that amount.

After you satisfy the deductible, the plan will reimburse you for a percentage of your eligible expenses and you will pay the balance. The percentage you pay is called your coinsurance percentage. In many cases, you must complete claim forms and file claims with the dental health care company to receive payment of benefits. The plan will not cover any charges above the allowable amount.

When you enroll, you may select any primary dentist from your plan's network provider directory for each covered family member. Your enrollment materials will request your primary dentist's name, or a code for that primary dentist from the network provider directory. It's a good idea to check with your dental care company before you select a primary dentist. Some primary dentists have "full" practices and cannot accept new patients, and others may no longer be participating in the network.

Yes. You or a covered family member may change primary dentists for any reason. Just call the member services number on your ID card.

You may not need to file a claim form when you go in-network. When you do need to file a claim form, as you need to do in most cases when you go out-of-network, your dentist may handle your expense in one of two ways. Most dentists require you to pay the bill right away. In this case, get a receipt and file it with a claim form to be reimbursed. If the expense is covered, you will be reimbursed for part of the bill. To file a claim, follow the instructions on the claim form. If you have more than one dental health insurance plan and have received an Explanation of Benefits (EOB) form from another plan, be sure to include a copy with your claim. Sometimes dentists are willing to wait for payment. In this case, you or your dentist will file the receipt and completed claim form with your dental health care company. The dental health care company will pay the dentist for the part of your expense the plan will cover. The dentist will then bill you for the part the plan did not pay.

If it's not an emergency and you need care while traveling, call your dental health care company at the member services number on your ID card for referral to an in-network provider. In a true emergency, such as an accident that broke your teeth or severe dental pain, get the care you need as quickly as you can. If you are able, contact your dental health care company even in an emergency. Your dental health care company can help you decide where to go for care. However, even if you are unable to contact your dental health care company, get the care you need. Even if you need to go out-of-network, your plan may cover emergency care at in-network benefit levels as long as you follow the plan rules. Check to see how your plan defines a dental emergency.

A deductible may only apply, or may be higher, when you obtain care out-of-network. A deductible is the part of eligible expenses you must pay before the plan begins to pay a percentage of your eligible expenses.

Yes. Some of your expenses will not count toward your deductible. For example, amounts your dentist charges above the plan's allowable amount for a given service will not count toward your deductible.

Coinsurance is the percentage of eligible expenses you pay after you meet your deductible. With a dental point-of-service plan, coinsurance may not apply to in-network expenses, or may only apply to certain types of services.

A copayment generally applies to in-network care. A copayment is the fixed amount you pay at the time you receive services.

Predetermination of benefits is the process by which a dental care company reviews the proposed treatment and tells you and your dentist how benefits may be paid. Generally, with a dental point-of-service plan, fees for in-network services are very straightforward, and predetermination of benefits is not necessary to avoid surprises. However, you can always discuss costs and treatment options with your primary dentist. When you obtain care outside the network, it's a good idea to obtain a predetermination of benefits before expensive services are performed. Have your dentist complete a form showing the proposed treatment and submit it to your dental care company. The dental care company will send your dentist an explanation of what benefits would be covered and what you would have to pay out of your pocket. You can then discuss your treatment options with your dentist.

The terms "allowable amount," "U&C amount" or "R&C amount" vary by plan but refer to the same thing. The allowable, usual and customary or reasonable and customary amount is the amount usually charged for a given service by most providers in your area. This amount is determined by your dental plan. If your dentist charges you more than this amount, you will not only be responsible for your deductible and coinsurance, but also for the entire difference between the U&C amount and the amount your provider charged. This concept only applies for out-of-network care, because network dentist fees are by definition allowable amounts. For example, suppose you receive a service out-of-network for which the "U&C amount" is $100 but your dentist charges you $110. The dental care company will multiply the percentage the plan pays for that service by $100. So even if the service were covered at 100%, you would pay the $10 difference ($110 charge minus $100 U&C).

Covered services are services covered by the plan. No dental plan covers everything. If you obtain services that are not covered services, you pay the full cost for those services.

An out-of-pocket maximum is the most you would have to pay “out of your own pocket” for eligible expenses. Not all plans have an out-of-pocket maximum, and some plans have different maximums for in-network and out-of-network services. Check your Benefits Summary for details. With a plan that has an out-of-pocket maximum, once you reach the out-of-pocket maximum for a given year, the plan would pay all eligible expenses for covered services until any lifetime maximum benefit is reached. Not all expenses count toward an out-of-pocket maximum. Expenses for services that are not covered under the plan and amounts over any allowable amount limit would not count toward your out-of-pocket maximum.

A lifetime maximum is the most that will be paid by the plan for covered services for a given plan member. Not all plans apply a lifetime maximum, and some plans have different lifetime maximums for different services or for in-network and out-of-network services. Once you reach the lifetime maximum, you pay all expenses over that amount.

An open access dental point-of-service plan works for you in two ways: in-network and out-of-network. When you enroll in an open access dental point-of-service plan, your plan may or may not ask you to select a participating dentist for each enrolled family member. If you are asked to select a primary dentist, you may select any participating primary dentist from your plan's network provider directory. With an open access point-of-service plan, you may see any provider in the plan’s group of network providers without getting a referral. When you see a network provider, this is considered "in-network." When you see a provider outside the network, this is "out-of-network." You choose whether to go in-network or out-of-network each time you need care. However, if you choose to go out-of-network, you will pay a larger share of the cost.