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Insurance
Information

HELPFUL INSURANCE INFORMATION

Thodas & Tran General Dentistry accepts all PPO dental insurance plans as an out-of-network provider.

 

Please let our office know if your dental insurance has changed at least 1 week prior to your scheduled appointment. 

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All payments and co-payments are expected at the time of service

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We submit all claims electronically as a courtesy on your behalf 

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Our knowledgeable staff is available by phone and email to help you navigate your insurance questions and help you understand and maximize your benefits.

Patients with Delta Dental

We accept Delta Dental PPO and Premier plans as an out-of-network provider. Payment in full will be obtained at the time of service. Our staff will electronically submit your Delta Dental claim as a courtesy on your behalf, and Delta Dental will then send its reimbursement directly to the subscriber on the plan.

How Delta Dental is different from other out-of-network plans

Patients with Delta Dental

With Delta Dental PPO dental insurance plans,  Delta Dental does not allow assignment of benefits to be made to our office as an out-of-network provider 

  • Delta Dental requires that we collect payment in full at the time services are rendered

  • As a courtesy, we submit your dental insurance claim electronically to Delta Dental on your behalf

  • Delta Dental then processes the claim and mails the benefit check directly to the subscriber on the plan in the subscriber's name, within 2-4 weeks of receiving the claim

  • Note: There are a very small minority of Delta Dental plans that allow reimbursement directly to the provider - we check for this when we verify your insurance benefits in advance of your appointment

Patients with PPO Plans

With other PPO dental insurance plans, the insurance companies allow assignment of benefits to be made directly to our office as an out-of-network provider. With this structure, prior to your scheduled dental appointment

  • our practice contacts your insurance plan directly via phone and/or through their website to verify that your dental insurance plan is active

  • we review your benefits in detail to best estimate your insurance plan's anticipated payment for each procedure

  • any applicable co-payment is collected at the time services are rendered

  • we submit your dental insurance claim electronically 

  • the insurance company mails us the benefit check within 2-4 weeks of receiving the claim

  • any over/underpayment is addressed by sending you a refund or a statement showing the amount still to be collected

Insurance FAQ

Can I still come to you when you are out-of-network?
Yes, definitely! We accept all PPO plans. The majority of our patients already have out-of-network insurance plans. The benefit of having a PPO dental insurance plan is that you are able to choose your dentist and you are not limited to in-network providers.


Will I need to pay for everything out-of-pocket?
No, thank goodness! Fortunately PPO plans allow us to accept assignment of benefits as an out-of-network provider (**except for Delta Dental, see explanation above for details**). This means that your PPO plan will reimburse our office directly for covered services associated with your dental appointment. You are only responsible for your patient portion. After the appointment is complete, as a courtesy, we will electronically submit your insurance claim to your insurance company directly on your behalf. You will continue to only be responsible for your estimated patient portion after we receive the payment from insurance.


How will my patient portion (co-pay) work when Thodas & Tran General Dentistry is out-of-network?
For patients using their out-of-network PPO benefits, for preventive and diagnostic services such as routine examinations, cleanings, fluoride and xrays there will often be either no or very minimal out-of-pocket cost. If you come to see us and you are out-of-network, it simply means that you are responsible for the difference (IF ANY) between our fee for a procedure and the "Allowed Fee" set by your insurance. Our fees are based on Usual and Customary Rates (UCR) for dentists in our local geographic region. Most Cigna plans base out-of-network benefit reimbursement on UCR. Less commonly, the out-of-network benefits will be limited by a Fee Schedule determined between your employer and your insurance company.


What is a pre-treatment determination?
The pre-treatment estimate or determination is when the patient’s estimated treatment plan for an upcoming appointment is submitted electronically by our office as a courtesy to the family directly to the insurance company in advance of the appointment. The insurance company reviews the patient’s specific benefits plan, then mails a document to the subscriber on the plan and our office with a treatment cost estimate. This process takes at least two weeks for most insurance plans. Delta Dental of California, Georgia and Pennsylvania plans typically allow us to obtain same-day pre-treatment authorizations in most cases. In some cases the insurance company may delay processing and if the pre-treatment authorization is not received by our office by appointment date, we will estimate your benefits based on what is standard for an average plan. The estimate is based on the type of plan, eligibility, current plan benefits and the amount remaining in your annual maximum. Typically, plans will mail the estimate to the subscriber’s address and to our office. Even with preauthorization, insurance will never guarantee payment. We verify eligibility for every patient, and we truly make every possible effort to ensure accuracy because we want you to have a great experience. However, every insurance company is different. They will not guarantee coverage or eligibility and can even refuse to provide specific dollar figures. If specifics are not provided by your insurance company, we will estimate based on what is standard for an average plan. Ultimately, your actual coverage may be different from this number. You are responsible for any unpaid amount by your insurance company. Actual benefit payments are determined only when a claim is processed by your insurance company.


What if my employer has chosen a Fee Schedule for my plan?
If your employer has selected a plan that bases out-of-network coverage off of a Fee Schedule, this means that the plan will pay the designated percentage of coverage for any given service up to the fee that has been agreed upon between your employer and the insurance company, i.e. the Allowed Fee. The Allowed Fee is lower than the UCR. For patients with a Fee Schedule, it can take a little extra research to help estimate what your benefits will be and the estimated treatment plan is based upon the information made available to our office by your insurance company. Upon request by email, we can submit a pre-treatment authorization to help obtain more information from your insurance plan at least two weeks in advance of your appointment. At times, the insurance company will only provide our office with the precise coverage amounts when the claim for dental services is actually processed and the Explanation of Benefits (EOB) is mailed to both the subscriber and our office. In those cases if there is any balance remaining on your account after the claim is processed by your insurance company, a follow up statement will be mailed to you afterwards and you will be responsible for the balance.

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Any additional questions? You can email us at info@thodasdds.com or give us a call at (650) 872-2080 and we are here to help

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