Ask Kaylie

Specific dental-insurance questions answered from carriers' own policy documents and what Kaylie measures across the practices it serves.

Downgrades & alternate benefits

Does UnitedHealthcare downgrade fillings? — UnitedHealthcare downgraded 1.9% of posterior composites and 0.3% of crowns — the lowest rate of any large commercial carrier that downgrades at all — and its federal brochure says the rule reaches molars only.
Is a downgrade decided by the insurance company or the employer? — The same carrier and the same code split almost evenly at carrier level and land near-unanimously once you sort by employer group — with the carriers' own documents saying why.
Does Aetna downgrade fillings? — Aetna downgrades 12.3% of posterior composites and 18.6% of crowns — and stated every single one of them on the remittance.
Does Ameritas downgrade fillings? — Ameritas downgrades 48.6% of posterior composites and 45.6% of crowns — and 36.7% of its downgrades carry no remark, the highest silent share we measure.
Does Cigna downgrade fillings? — Cigna pays 28.5% of posterior composites at the amalgam fee and says so on almost all of them — but the answer flips completely between two employer groups.
Does Delta Dental downgrade composites? — Eight Delta member companies, eight different tooth scopes for the same posterior composite rule — plus the Colorado plan where the office may not bill the patient the difference.
Does Delta Dental downgrade crowns? — Delta pays 8.5% of crowns at a cast-metal allowance — and a third of those downgrades arrive with no remark at all.
Does Delta Dental downgrade fillings? — Delta pays 15.0% of posterior composites at the amalgam fee — and which member company wrote the plan changes the answer as much as which employer bought it.
Does Guardian downgrade fillings? — Guardian downgrades 45.8% of posterior composites and 46.2% of crowns — the highest rates of the large carriers — and one in five of those downgrades carries no remark.
Does MetLife downgrade fillings? — MetLife pays 27.1% of posterior composites at the amalgam fee, 45.3% of crowns at a cast-metal fee — and states essentially every one of them on the remittance.
Does Principal downgrade fillings? — Principal downgrades 11.2% of posterior composites and 10.2% of crowns — a low rate on a small sample, with 16.7% of its downgrades carrying no remark.
What amalgam code is a posterior composite downgraded to? — The four posterior composite codes, the amalgam codes they are paid as, which teeth are in scope, and the carriers that exclude premolars or a single surface.
What does insurance downgrade a porcelain crown to? — D2740 and the PFM crown codes, the full-cast codes they are paid as, and the same substitution applied to bridge retainers and pontics.
What is a dental insurance downgrade (alternate benefit provision)? — The plain definition of an alternate benefit provision, the standard code pairs, why a dental HMO surcharges instead, and how the patient's share actually moves.
Which dental insurers downgrade crowns? — Crown downgrade rates for eleven carriers, the cast-metal codes a porcelain crown is paid as, and the three different tooth scopes carriers publish.
Which dental insurers downgrade without telling you? — Seven carriers measured on paid claim lines: how often each one pays the cheaper alternate benefit without saying so anywhere on the remittance.
Why Did Insurance Pay Half of What I Expected for This Filling? — Understanding how insurance companies use "least expensive alternative treatment" to downgrade composite fillings to amalgam fee schedules—and how to protect your patients from surprise bills.

Sedation & anesthesia

Can you bill local anesthesia separately on a dental claim? — Anthem, Delta Dental, MetLife, Aetna and United Concordia all publish the same rule on D9210 and D9215: the local anesthetic is part of the procedure fee and is not payable separately — and Delta, MetLife and Aetna add that it is not billable to the patient either.
Does Aetna dental cover sedation? — Aetna publishes five criteria for general anesthesia and IV sedation — and is the one carrier that names anxiety as a qualifier, with a harm test bolted onto it.
Does Cigna dental cover sedation or anesthesia? — Cigna publishes a short list of qualifying medical conditions and a longer list of qualifying procedures — and medical necessity is the denial reason on more than a quarter of the deep sedation lines we see.
Does Delta Dental cover sedation? — Delta pays deep sedation about half the time, denies nitrous oxide unless the contract bought it, and caps anesthesia at one hour that cannot be billed to the patient.
Does dental insurance cover sedation for children? — Every carrier picks a different age and none of them agree — three, five, six, seven, fifteen, twenty, twenty-one — and one declines to publish a number at all.
Does dental or medical insurance cover dental anesthesia? — Cigna's dental guideline qualifies a child three or younger; Cigna's medical policy qualifies one seven or younger. Same carrier, same appointment, two rulebooks.
Does Guardian dental cover sedation? — Guardian pays deep sedation about three times in four — but only alongside surgery, and its nitrous oxide denials are age denials.
Does Medicaid cover dental anesthesia? — Seven state programs, seven different rules — 45 minutes in Alabama, $238 a unit in Wisconsin, $780 a day in Georgia, and a California rule that denies an already-authorized claim.
Does MetLife dental cover sedation? — MetLife pays deep sedation on about six lines in ten and bundles nitrous oxide into the procedure fee — and on one of its dental HMO plans general anesthesia carries a $100 lifetime maximum.
How long will insurance pay for dental sedation? — Seven payers publish seven different limits on a single appointment's anesthesia — from 30 minutes to two and a half hours, plus one that caps the dollars instead.
Is D9248 gone in 2026, and what are the new sedation codes? — D9224 and D9225 for general anesthesia with an advanced airway and D9244 through D9247 for enteral and non-IV parenteral sedation arrived for 2026; D9248 was deleted on 31 December 2025.
Is general anesthesia covered for wisdom teeth removal? — Two or more impacted third molars in one visit is a listed qualifier at most carriers; one tooth usually is not — and the count is decided when the case is planned.
Is nitrous oxide (laughing gas) covered by dental insurance? — Nitrous oxide is the most inconsistently covered code in the sedation family — paid on 4.2% of Cigna lines and 67.1% of United Concordia lines in the same claims data.
What does a 'per lifetime' limit on anesthesia mean? — Deep sedation and IV sedation bill in 15-minute increments, so a count stated 'per lifetime' on those codes is minutes at one appointment — not a number of sedations forever.
Why was my dental anesthesia claim denied? — Nine distinct mechanisms deny a sedation line — and the sentence printed on the explanation of benefits frequently names none of them.
Will insurance cover sedation for dental anxiety? — Commercial plans almost never pay for sedation on anxiety alone; several Medicaid programs do. The word that decides it, in the carriers' own documents, is 'only'.

Missing tooth clause

Do Blue Cross Blue Shield dental plans have a missing tooth clause? — The Blues are separate companies — Illinois, Texas and South Carolina individual dental products carry the clause, Alabama's federal plan runs a 24-month version, and Anthem plans branch on the employer's contract.
Does Aetna have a missing tooth clause? — Aetna calls it the Tooth Missing But Not Replaced Rule — a positive requirement that the tooth came out while the policy was in force, plus a 5 or 8 year abutment condition.
Does Cigna have a missing tooth clause? — Cigna publishes no carrier-wide missing tooth rule. Some Cigna DPPO plans write it as a limitation — 50% of the payable amount for 12 months — and others state none; the plan document decides.
Does Delta Dental FEDVIP have a missing tooth clause? — Delta Dental's FEDVIP brochure removed the missing tooth clause effective 1 January 2025 — what it now covers, what it still excludes, and why 2024 claims are unaffected.
Does Delta Dental have a missing tooth clause? — Some Delta Dental plans have a missing tooth clause and some do not — and in 2025 it moved in both directions, with measured member-company shares.
Does dental insurance cover congenitally missing teeth? — Congenitally missing teeth are excluded by a separate provision that survives even where the missing tooth clause has been removed — and Medicaid programs treat them the opposite way.
Does Guardian have a missing tooth clause? — Guardian's PPO default excludes a prosthesis replacing teeth lost before coverage unless the same appliance also replaces a tooth lost afterwards — and congenitally missing teeth are not carved out.
Does MetLife have a missing tooth clause? — MetLife publishes no carrier-wide missing tooth rule — the employer's plan document decides, and MetLife's federal FEDVIP brochures do not state one.
Does the missing tooth clause apply to bridges, partials and dentures? — Yes — but on a bridge it usually denies only the pontic while the retainer crowns are judged on their own merit, and a crown on a tooth that is still present is outside the clause.
Does the missing tooth clause apply to dental implants? — Yes — carriers that write a missing tooth clause name implants, implant crowns and implant-supported dentures inside it, and an implant rider does not override it.
Does United Concordia have a missing tooth clause? — Split answer — the TRICARE Dental Program states the missing tooth exclusion does not apply, while United Concordia's commercial PPO policy defers to the group contract.
What are the exceptions to the missing tooth clause? — The five documented exceptions to the missing tooth clause, the plans where it expires after 12 or 24 months, and what carries over when the patient changes carriers.
What is a missing tooth clause? — A plain-words definition with the carriers' own wording, how often plans carry it, and why the employer group predicts the answer better than the carrier does.
Which Delta Dental plans have no missing tooth clause? — The named Delta Dental products that state they have no missing tooth clause, and the member companies where Kaylie measured how rare the clause is.
Which dental insurance plans have no missing tooth clause? — The named plans that state they have no missing tooth clause — federal, state-employee, military and commercial — and how often plans answer that the clause does not apply.
Why was my bridge denied for too many missing teeth? — Alternate-benefit rules that count how many teeth are missing now — not when they were lost — and get blamed on the missing tooth clause.
How Do I Avoid the Missing Tooth Clause Disaster? — The missing tooth clause might be the cruelest trap in dental insurance. Learn how to identify these restrictions before making promises you can't keep.

Frequency limitations

Does my old insurance count against my new dental plan? — Often yes. Several plans count a service performed before your coverage started; others count only what they paid for. The sentence is in the plan document.
How often does insurance cover fluoride? — Fluoride runs from once a benefit year to six a year on one state programme, depending on the plan and the patient's age band. Two per year is common but is not a rule.
Can I get a third cleaning if I'm pregnant or diabetic? — Many plans add a cleaning for pregnancy or a chronic condition, but the extra is gated on paperwork: a physician statement, a diagnosis, or registration.
Do D4910 and D1110 share a frequency? — On roughly two thirds of published plans they draw on one counter. On the rest they run separate limits and one carrier deliberately interleaves them.
Does a D4346 cleaning use up a regular cleaning? — On many plans yes, but carriers do it six ways: a pooled counter, a replacement, an in-lieu-of, a second clock, a blackout window, or a flat disqualification.
How often does dental insurance cover cleanings? — Two a year is the common number but not the rule. Published plans run from one adult cleaning a year to three and the wording decides when you are due.
How often does insurance cover a dental exam? — Two exams a year is the common answer and nearly every plan pools the exam codes into one counter — so a comprehensive or emergency exam spends a routine slot.
How often does insurance cover dental x-rays? — The full-mouth series and the panoramic image usually share one window of one to five years. Bitewings usually run one or two sets a year and split by age.
How often does insurance cover perio maintenance (D4910)? — One to four a year on published plans, most often two to four, and usually pooled with your cleanings. A documented history of periodontal therapy is the first gate.
How often does insurance cover scaling and root planing (D4341/D4342)? — Once per quadrant every 24 months is the commercial norm. Published plans run from 24 months to three years and many state no cap at all.
How often does insurance cover sealants? — Once per tooth every three years is the commonest sealant rule, but plans also state 48 months, 60 months and once per lifetime. Tooth scope is a separate rule.
How often will insurance replace a crown? — Five, seven or ten years depending on the plan, measured from the existing crown's placement date, with an unserviceability test on top of the clock.
Is a dental frequency counted per person, per tooth, or per quadrant? — Seven denominators are in commercial use: per patient, per provider, per tooth, per surface, per quadrant, per arch and per lifetime.
Is my dental plan on a calendar year, benefit year or rolling 12 months? — Three bases exist: a calendar year resetting 1 January, the group's own benefit year, and a rolling window counted back from your last visit.
What are Aetna's dental frequency limitations? — Aetna labels its own frequency table a default and puts the binding rules in clinical policy bulletins. Kaylie has not measured Aetna frequency refusals.
What are Cigna's dental frequency limitations? — Cigna publishes no carrier-wide frequency schedule. Its own wording is the tell: Consecutive Years is a rolling window and Policy Year is the group's year.
What are Delta Dental's frequency limitations? — Delta's dentist handbooks set one imaging default absent contract language: five years on the full-mouth series and panoramic. Delta's own federal plan says 48 months.
What are MetLife's dental frequency limitations? — MetLife publishes no carrier-wide frequency schedule. Its federal, individual PPO and DHMO products count on three different bases — the plan document decides.
What does '1 per 36 months' mean? — It means not yet. A rolling window counts backwards from your last date of service — and plans differ on whether it is counted to the exact day or to the month.
Who pays when I go over the frequency limit? — Five answers appear in carrier documents: you owe the network rate, the dentist writes it off, you owe full charges, a copay, or a cheaper code.

Age limits

At what age does ACA pediatric dental coverage end? — Under 19 means through 18, and the benefit usually runs to the end of the month or the plan year in which the child turns 19 rather than to the birthday.
At what age does D1120 become D1110? — Two federal plans state it identically: age 13 and under bills as D1120 and age 14 and over as D1110. Medicaid programs split at 12, 13 or 14 instead.
Do 'through age 18', 'under 19' and 'up to age 19' mean the same thing? — Through age 18 and under 19 both mean covered through 18. Up to age 19 cannot be resolved from the words and has to be confirmed with the payer.
Do D1206 and D1208 have the same age limit? — Not always. Cigna age-denies 26.6% of D1206 lines against 16.7% of D1208; Guardian 18.7% against 5.2%. One plan covers varnish for adults and gel for children.
Does 'stop age 19' mean 18 or 19? — It means covered through 18. On plans stating a fluoride stop age of 19 the per-code upper bound read 18 on 47 of 47 measured benefit checks.
Does my child lose braces coverage on their birthday? — On some plans yes, and mid-treatment. One product booklet ends orthodontic benefits at the end of the month the member turns 19 even for a case already banded.
How do Medicaid dental age limits differ from commercial plans? — Medicaid draws the child boundary at 21 rather than 19, and EPSDT can override published limits. Some Medicaid rules are tighter than commercial ones.
Is there an age limit on nitrous oxide coverage? — On several plans nitrous is limited to young children or to a documented medical condition. Guardian age-denied 37 of 185 D9230 lines; Delta Dental 3 of 1094.
Until what age does insurance cover a space maintainer? — Federal plans cluster at under age 19 and one runs to 22. Commercial caps run lower, from through age 13 to under 19, and are often once per space per lifetime.
What is the age limit for fluoride varnish (D1206)? — Age denials on D1206 ran from 40.5% at Ameritas and 26.6% at Cigna down to 0.7% at United Concordia. Published caps resolve to a spread of 11 to 25.
What is the age limit for orthodontic coverage? — Dependent children to age 19 is the commercial default. Adults are covered more often than expected, mostly on federal plans with a separate lifetime maximum.
What is the age limit for sealants (D1351)? — Most commercial sealant caps fall between 13 and 19, with one federal plan at 22, and molars only is the default. Only 5.5% of Cigna D1351 lines and 0.5% of Guardian's are denied for age.
When does insurance stop paying for fluoride? — Resolved to the oldest age still covered, published caps run from 11 to 25. Some plans never stop: one federal plan covers fluoride varnish twice a year for members over age 22.
Which teeth are covered for sealants? — Most plans pay sealants on permanent first and second molars only. Some name the eight teeth outright, and one carrier pays only on the four first molars.
Why does my plan show an ortho age limit of 12? — The 12 usually sits on habit-appliance codes D8210 and D8220, not comprehensive orthodontics. On 41 of 41 plans carrying one there was no comprehensive cap.
Why was fluoride denied for my 20-year-old dependent? — Eligibility to 26 says who is on the plan. A benefit age limit says which services that person can still use. Fluoride caps resolve to anywhere from 11 to 25.
Why was my child's cleaning denied for age? — Almost always a coding mismatch, not a coverage gap: the cleaning was billed on the adult code D1110 for a patient the plan counts as a child. The fix is D1120.

Bundling & same-day billing

Can you bill a cleaning and scaling and root planing on the same day? — Generally no. Delta treats the cleaning as a component of same-day scaling and root planing and Alabama Medicaid bars the pair outright.
Does a panoramic x-ray use up the full-mouth-series benefit? — On most plans yes - the pano and the full-mouth series share one allowance. Delta and United Concordia both allow one or the other in a five-year period.
How many x-rays equal a full-mouth series? — No single number. MetLife counts nine periapicals, Alabama Medicaid 14 films, a Delta Medicaid policy rebundles past 12 - and Delta and Liberty use a fee test with no count.
If insurance bundled it, do I still owe for it? — Not if the dentist is in network. Five carriers state that a participating dentist may not bill the patient for a bundled service. Out of network differs.
Is a pulp cap billable with a filling? — No. Indirect pulp caps were bundled on 100% of the lines we measured at Delta and Cigna. Delta calls the pair a single complete restorative procedure.
Is gingival irrigation ever paid by dental insurance? — Not at Delta Dental, MetLife or United Concordia. All 220 Delta lines for D4921 were bundled. Billed alone it is non-covered; billed with periodontal treatment it is inclusive.
Is nitrous oxide bundled into IV sedation or general anesthesia? — Yes. Delta bars a separate D9230 fee alongside IV sedation or general anesthesia and the CDT descriptor Cigna prints puts nitrous inside the sedation code.
What does a 'bundled' or 'inclusive' denial look like on the EOB? — CARC 97 with RARC M15 or N20 beside it and a sentence saying the fee is included in another completed service. Bundling is the 7th most common denial reason.
What is already included in the price of a filling or a crown? — Delta lists adhesives liners bases pulp caps local anesthesia polishing and caries removal inside the filling fee. A crown fee includes the laboratory bill.
What is bundling vs unbundling in dental billing? — Bundling is the carrier paying two codes as one. Unbundling is billing components separately when one comprehensive code exists - and carriers rebundle it.
When is a core buildup paid separately? — When the documented loss of tooth structure justifies it - Delta names 50% or more of the tooth lost and Cigna requires decay or fracture.
Why did insurance pay my panoramic x-ray and bitewings as a full-mouth series? — A pano taken with bitewings on one date trips most carriers' complete-series test. MetLife bundled 28.4% of panoramic lines. The excess is a network write-off.
Why was my core buildup denied as included in the crown? — Cigna denied 46.2% of core buildup lines as included in another procedure. Carriers pay D2950 only when the documented loss of tooth structure justifies it.
Why was my gum trimming or crown lengthening bundled into the crown? — Carriers treat preparing the gum for a crown as part of the crown. MetLife Delta and Liberty all bar a separate D4249 fee on the crown-preparation day.
Why wasn't the socket packing after my extraction paid? — Intra-socket material D7922 was bundled on every line we measured at Delta and Cigna. Carriers treat it as part of the extraction and it cannot be billed.
Why were my periapicals bundled into the full-mouth series? — Single films taken on the same day as a D0210 are denied as integral by Aetna United Concordia and Guardian. MetLife bundled 5.7% of first-periapical lines.
Why weren't the x-rays taken during my root canal paid separately? — Working-length and final-fill films are part of the endodontic procedure at MetLife Aetna United Concordia Delta and Guardian. The patient is not billed.

Denials & EOB codes

How long do I have to appeal a dental claim denial? — Most published dental appeal ladders run a 180-day first level, a 30 to 60 day second level, then an external review. Aetna states one level.
How long do I have to file a dental claim? — Filing deadlines in published dental provider manuals run from 95 days to 24 months. Every row here is quoted from a named carrier or public-programme document.
Can I bill the patient for this denial? — The group code decides, not the reason code. CO and PI are the office's write-off and PR is the patient's, and the same denial can be either one.
Do I have to pay if my dentist filed the claim late? — Usually not when the dentist is in your network: the contract normally makes a late-filing denial the office's write-off rather than the patient's bill.
How do I read a dental EOB? — Read every EOB line in one order: billed, allowed, plan paid, patient responsibility, then the group code, then the remark code that carries the actual rule.
Is CO-45 on a dental EOB a denial? — CO-45 is the in-network write-off: the gap between the office's fee and the plan's allowed fee. It rides paid lines and is never the patient's money.
What do CO, PR, OA and PI mean on a dental EOB? — CO PR OA and PI are the group codes on a dental EOB. They decide who owes the money — not the number beside them. What each one means and what to do.
What do Delta Dental's denial codes mean? — Delta prints its own three-character policy codes beside the standard X12 codes. Its published mapping lists 938 of them and 433 map to a single code, 96.
What do I do when a dental claim is denied for frequency? — Frequency is 14.4% of dental denials measured across 37 practices. Pull the patient's history first — an appeal only works when the carrier's count is wrong.
What does 'processed according to contract provisions' mean? — The phrase names no rule. It can sit on a bundling rule a frequency cap or a condition the office could have met. What to read instead and what to ask.
What does CO-16 mean on a dental claim? — CARC 16 means the claim is missing information — correct the field and resubmit. But a bare 16 on a Guardian EOB is a frequency limit: two opposite fixes.
What does CO-204 or PR-204 mean on a dental EOB? — 204 means the service is not covered under the patient's plan. PR-204 is the patient's bill; CO-204 and PI-204 are the write-off. Same code opposite answers.
What does CO-29 mean on a dental claim? — CARC 29 means the filing deadline expired. Whether the office writes it off or bills the patient turns on the contract — one carrier prints it both ways.
What does N640 mean on a dental EOB? — N640 is a remark code meaning more of this service than the plan allows in the period. It moves no money — the reason code beside it does.
What goes in a dental claim appeal? — Liberty Dental Plan publishes the full contents list for a provider payment dispute, and states that an incomplete one is upheld rather than returned.
What is a RARC vs a CARC on a dental EOB? — A CARC is the money code and always carries a group code. A RARC is the explanation and moves nothing. On dental claims the RARC is where the real rule appears.
What is the difference between a denied and a rejected dental claim? — A rejected claim never reached adjudication and carries no CARC — correct and resubmit. A denied claim was judged and can be appealed. The fixes are opposite.
What is the difference between CO-119, CO-35 and CO-149? — 119 covers the annual maximum and frequency limits both. 35 is the lifetime maximum. 149 is a per-service lifetime cap. Three codes three fixes on a dental EOB.
What is the difference between CO-97, CO-96 and PR-96? — 97 means bundled into another service. 96 means non-covered and names no rule at all. CO and PR decide who pays. How to tell the three apart on a dental EOB.
What should I send when the EOB says 'send documentation'? — A documentation request is usually a held decision rather than a refusal. Send exactly what the remark code names and send the whole of it the first time.
Which dental denials are worth appealing? — Appeal the denials a person judged on evidence. Remark code N10 sits on 122 of Delta's 938 policy codes and marks the reviews better evidence can move.
Why are Medicaid dental claim denials different? — Tighter filing windows, forfeiture language, a State Fair Hearing tier commercial plans do not have, and public code libraries you can actually look up.
Why do dental claims get denied? — Every denial reason ranked by volume across 37 dental practices and 170+ payers. Not covered is 22.3%. The missing tooth clause everyone worries about is 0.1%.
Why isn't my dental EOB's denial code in any code list? — Of the forty most-printed code tokens on dental EOB lines only about a dozen are national X12 codes. The rest are carriers' private libraries.
Why was my dental claim denied as a duplicate (CO-18)? — CARC 18 means the payer already processed this exact procedure. Check whether the first claim paid before doing anything — often it is not a denial at all.

Appeals & reconsiderations

Should I appeal a Cigna dental denial? — Cigna publishes a numbered policy per procedure, each with an explicit not-allowable list — so you can look up whether a denial is arguable before you write a word.
Should I appeal a denied core buildup? — The wording of the denial answers it. "We could not determine" is a document you can send; "the fee is included in the crown" is a decision already made.
Should I appeal a denied crown? — Read the reason before you write. Carriers publish crown criteria as checkable facts, and only some crown denials are a judgement an appeal can move.
Should I appeal a denied deep cleaning (scaling and root planing)? — Only if the radiographs show bone loss. Five carriers publish the same criterion in different words, and pocket depth alone satisfies none of them.
Should I appeal a denied dental implant? — Usually not — resubmit it. Delta Dental says most implant denials on plans that do cover implants are coding errors, and a plan that excludes implants is a contract term.
Should I appeal a denied root canal? — Endodontic denials are judged on the film. Carriers publish exactly what disqualifies a tooth — and most of those things are visible before the appeal is written.
Should I appeal a denied wisdom tooth extraction? — Aetna publishes the pathology that justifies removing an impacted third molar, and the documentation it wants for each one — and says crowding is not on the list.
Should I appeal a denied x-ray? — Most denied radiographs are a frequency limit or a bundling rule, and neither moves on appeal. The ones worth acting on are usually a resend, not an argument.
Should I appeal a MetLife dental denial? — MetLife's reviewers only recommend, and its manual offers no peer-to-peer call — so a MetLife appeal is a document exercise. Its largest denials are imaging, and it publishes the rule that causes them.
Which dental denials are not worth appealing? — Roughly three in five denied dental lines state a plan term, which no narrative reaches. Two public programmes publish the complete list of what cannot be appealed at all.

Networks & fee schedules

Are fee schedule, allowed amount and contracted fee the same thing? — Three terms carriers use for three different objects: the list, the number applied to one claim line, and the price your contract sets.
Can you charge your full fee for a service the plan doesn't cover? — MetLife's contracted fee applies to non-covered services too — except in the 43 states whose laws say otherwise, listed in the carrier's own provider manual.
Cigna DPPO vs DPPO Advantage vs Total DPPO vs DHMO: what's the difference? — Advantage is a deeper-discount fee schedule nested inside the Total DPPO network, not a separate product — and the DHMO is a different product entirely.
Delta Dental PPO vs PPO plus Premier vs PPO MAC: what's the difference? — Three Delta products sold under the PPO name pay a Premier dentist three different amounts for the same procedure — and the employer picked which one.
Delta Dental PPO vs Premier: what's the difference? — Premier is Delta's traditional fee-for-service network and PPO the reduced one — same contract, two allowances, and on a PPO plan a dentist in both networks is paid at the PPO rate.
How do I tell which fee schedule paid a dental claim? — We read 70 EOBs across 33 carriers and found zero non-boilerplate fee-schedule labels; of 45 carriers' claim-status portals, two stated a schedule identifier.
How does a dental HMO like DeltaCare USA pay the office? — A capitated plan pays a fixed monthly amount per assigned member whether or not they come in, and the patient's copay is payment in full.
In-network vs out-of-network dental: who pays the difference? — In network the office writes the difference off; out of network the patient owes it — and carriers spell out both rules in their own member documents.
MetLife PDP vs PDP Plus: what's the difference? — Two MetLife networks governed by one provider manual — different network composition, not interchangeable, and no published fee differential between them.
What does 'Delta Dental PPO Point of Service' mean? — Point of Service is an employer add-on to a Delta Dental PPO plan that pays Premier pricing when the patient sees a Premier dentist who is not in the PPO network.
What does 'Delta Dental PPO' on an insurance card mean? — Five products ship under the Delta Dental PPO name, the tier labels differ by state, and the one choice that decides a Premier office's payment is nowhere on the card.
What is a maximum allowable charge (MAC) in dental insurance? — Five carriers define it in their own words — and they do not all mean the same thing by it.
What is Delta Dental PPO MAC? — A MAC plan pays the PPO fee schedule to every tier, including Premier and non-participating dentists — and Delta's own product sheet says the patient owes the gap.
What is the difference between MAC and UCR in dental insurance? — One federal plan's own brochures show the switch: an 80th-percentile out-of-network allowance in 2021, the in-network fee schedule in 2026 — and the patient absorbed the difference.
What percentile does an out-of-network dental plan pay at? — Out-of-network allowances are often a percentile of area charges chosen by the employer — and the carrier will not tell you in advance what it comes to.
Why did insurance pay less than the fee the office billed? — Three numbers compete on every participating claim and the payer takes the smallest — and one of the three is a fee your office filed and may have forgotten.
Why Do My Out-of-Network Patients Keep Getting Surprise Bills? — Insurance companies hide their maximum allowable charge (MAC) during verification. Here's why your estimates are wrong—and how to fix it.

Ask Kaylie

How Do I Avoid Insurance Rules I've Never Even Heard Of? — Insurance companies bury plan-specific rules in hundred-page documents. Learn how to protect your practice from denials caused by restrictions you never knew existed.