Your plan booklet from your employer is the best guide to your own coverage. If you don’t find an answer here, your plan or benefits administrator can explain the details.
Common questions
What is “UCR” and how is it set?
UCR is the amount an insurance company is willing to pay for a procedure. There is no standard method for setting it, and it has no relationship to the fee your endodontist charges. Each plan sets its own amounts, often based on region, number of procedures and cost of living.
Why was my benefit different from what I expected?
Common reasons: you have already used some or all of your yearly benefit; your plan pays only a percentage of the fee; the treatment is not a covered benefit; you have not met your deductible; or you are still in a waiting period.
Why isn’t my recommended treatment covered?
Your endodontist recommends treatment based on professional judgment, not cost. Some employers or plans exclude certain necessary treatments to reduce their costs.
How will I know my portion of the bill?
Your portion depends on your plan’s UCR, your maximum benefit and other factors. We give you an estimate before treatment, but the exact amount is not known until your insurance company pays.
How do I read my Explanation of Benefits (EOB)?
Your EOB shows what your plan covered and paid. It lists the UCR, your co-payment or patient portion, remaining benefits, deductible and the amount paid.
How long does a claim take?
Processing time varies. Many states require insurers to pay claims within a set period, generally 15 to 60 days. If payment is late, you can contact your state insurance commissioner.
Will the office take my insurance?
Some endodontists sign contracts with insurers and accept the plan’s payment as payment in full; these are participating providers. Others accept insurance payments but are not bound by the plan’s fees, so you may owe a balance. Others ask you to pay and help you file for reimbursement. Call us and we will explain how your plan works with our office.
Glossary
- Assignment of benefits
- Your permission for the insurer to pay the endodontist directly.
- Claim
- A statement sent to your insurer listing the treatment, date and costs.
- Co-payment
- The part of the fee you owe after insurance pays its share.
- Coverage
- The benefits available to you under your plan.
- Deductible
- What you pay before your plan begins paying.
- EOB
- Explanation of Benefits: what your plan covered, did not cover, and paid.
- Participating provider
- A provider with a contract with your insurance company.
- Patient portion
- The amount you pay if insurance does not cover the full fee.
- Preauthorization
- Your insurer’s statement on whether treatment will be covered.
- Predetermination
- Sending a treatment plan to your insurer for review before treatment.
- UCR
- The amount your insurer is willing to pay for a procedure.
Adapted from patient information by the American Association of Endodontists.