What Does Usual and Customary Mean?
Almost all dental insurance companies use what is called a "usual, customary and reasonable" (UCR) fee guide. This means they set their own fee allowance for covered procedures. This is not based on what a dentist actually charges, but what the dental insurance company wishes to cover. For example, your dentist may charge $78 for a dental cleaning, but your insurance company will only allow $58 because that is the UCR fee they have set.
If your dental insurance policy requires you to go to a participating provider, you should not be charged the difference between these two prices. Remember, you will still be responsible for your co-payment. A contracted dentist generally has an agreement with the dental insurance company to write off the difference in charges. If the policy allows you to go to a dentist of your choice, check the insurance company's UCR fee guide against the fees that dentist charges. You may be required to pay the difference out of your pocket. However, you cannot put a price tag on quality dental care.
What is a "Missing Tooth" Clause?
More than 90 percent of dental insurance policies carry a missing tooth clause. A missing tooth clause protects the insurance company from paying for the replacement of a tooth that was missing before the policy was in effect.
For example, if you lost a tooth before your coverage started and later decided that you would like to have a partial, bridge or dental implant to replace the missing tooth, the insurance company would not have to pay for that service if they have a missing tooth clause in their dental plan.