Why Doesn't My Insurance Pay for This?

ADA American Dental Association

America's leading advocate for oral health

Having dental insurance or a dental benefit plan can make it easier to get the dental care you need. But most dental benefit plans do not cover all dental procedures. Your dental coverage is not based on what you need or what your dentist recommends. It is based on how much your employer pays into the plan. When deciding on treatment, dental benefits should not be the only thing you consider. Your treatment should be determined by you and your dentist.

How Dental Plans Work

Almost all dental plans are the result of a contract between your employer or plan sponsor and an insurance company. There are many ways in which dental plans are designed and how reimbursement levels are determined. The amount your plan pays is agreed upon by your employer with the insurer. Your dental plan is designed to share your dental care costs. It will most likely not cover the total cost of the services provided by our office. Most dental insurance plans cover between 50% - 80% of our fees for the services that we provide.

Your dental coverage is not based on what you or your family needs or what your dentist recommends. It is based on how much your employer pays into the plan. Employers generally choose to cover some, but not all of employees’ dental costs. You need to know how your dental plan is designed – and its limitations.


Below are some key terms used to describe the features of a dental plan:


  • ​​What is UCR (Usual, Customary, and Reasonable)

  • What is my Annual Maximum

  • Preferred Providers

  • Pre-existing Conditions

  • Coordination of Benefits (COB) and Nonduplication of Benefits

  • Plan Limits

  • Not Dentally Necessary

  • Least Expensive Alternative Treatment (LEAT)

  • Explanation of Benefits (EOB)

What is UCR (Usual, Customary, and Reasonable)?

Usual, customary and reasonable charges (UCR) are the maximum amounts that will be covered by the plan for eligible services. The plan pays an established percentage of you and your family's dentist fees or pays the plan sponsor’s “customary” fee limit, whichever is less.


Should this charge exceed the plan’s customary fee, this does not mean your dentist has overcharged for the procedure. Why? There are no regulations as to how insurance companies determine reimbursement levels, resulting in wide fluctuations. In addition, insurance companies are not required to disclose how they determine “usual, customary and reasonable” charges.


The terms "usual", "customary" and "reasonable" are misleading for several reasons:


  • UCR charges often do not reflect what dentists "usually" charge in a given area

  • Insurance companies can set whatever they want for UCR charges - they are not required to match actual fees charged by dentists

  • A company's UCR amounts may stay the same for many years - they do not have to keep up with inflation, for example

  • The insurance company may not have taken into account up-to-date, non biased, regional data in determining their reimbursement levels

  • Insurance companies are not required to say how they set their UCR rates - each company has its own formula

What is my Annual Maximum?

This is the largest dollar amount a dental plan will pay during the contact year. Your employer makes the final decision on maximum levels of payment through the contract with the insurance company.You are expected to pay the copayments and deductibles, as well as any costs above the annual maximum. Annual maximums are not always updated to keep up with the costs of dental care. If the annual maximum of your plan is too low to meet your needs, ask your employer to look into plans with higher annual maximums.

Preferred Providers

The plan may want you to choose dental care from a list of its preferred providers (dentists who have a contract with the dental benefit plan). The term preferred has nothing to do with the patient's personal choice of a dentist; it refers to the insurance company's choices. If you choose to receive dental care from outside the preferred provider group for you and your family, you may have higher out of pocket costs. Inform yourself about your plan's methods for paying both in and out of network dentists.

Pre-existing Conditions

A dental plan may not cover conditions that existed before you or your dependents enrolled in the plan. For example, benefits will not be paid for replacing a tooth that was missing before the effective date of coverage. Even though your plan may not cover certain conditions, treatment may still be necessary to maintain you and your family's oral health.

Coordination of Benefits (COB) and Nonduplication of Benefits

These terms apply to patients covered by more than one dental plan (for example, if you are insured by your employer and are also on your spouse's plan). Insurance companies want to know if you have coverage from other companies so they can coordinate your benefits. For example, if your primary (main) insurance will pay half your bill, your secondary insurance will not cover that same portion of the bill.


Benefits from all companies should not add up to more than the total charges. Even though you may have two or more dental benefit plans, there is no guarantee that any of the plans will pay for your dependent(s)'s dental care. Sometimes, none of the plans will pay for the services that are needed.


Nonduplication of Benefits is extremely tricky in that both policy holders could be paying premiums for dental insurance coverage for their dependents, but only one insurance company is going to make any payments. This allows insurance companies to collect premiums, but not have to make any payments to dental providers for your dependent's dental care. We always recommend that one policy holder discontinue dental insurance coverage if both coverages are non duplication of benefits as there is no benefit for paying for the second coverage.


Each insurance company handles Coordination of Benefits and Nonduplication of Benifits in its own way. Please check your plan for details.

Plan Limits

A dental plan may limit the number of times it will pay for a certain treatment. But some patients may need treatment more often than once for best oral health. For example, a plan might pay for teeth cleaning only twice a year even though you and/or your dependents needs cleaning four times a year. Be aware of the details in your dental plan but decide about the treatment based on what's best for you and your family's health, not just what may be covered.

Not Dentally Necessary 

Each dental benefit plan has its own guidelines for which treatment is "dentally necessary." If a service provided by your dentist does not meet the plan's "dentally necessary" guidelines, the charge may not be reimbursed.


However, that does not mean that the dental treatment was not necessary. Your dentist's advice is based on his or her professional opinion of you and/or your dependent's case. Your plan's guidelines are not based on your's (or the patient's) specific case. If your plan rejects a claim because a service was "not dentally necessary," you can follow the appeals process by working with your benefits manager and/or the plan's customer service department.

Least Expensive Alternative Treatment (LEAT)

If a plan has a LEAT clause, it means that if there is more than one way to treat a condition, the plan will only pay for the least expensive treatment. This is one way that insurance companies keep their costs down. However, the least expensive alternative is not always the best option. You should consult with your dentist on the best treatment option for you and/or your dependent.

Explanation of Benefits (EOB)

An EOB is a written statement from the insurance company, telling you what they will cover and what you must pay yourself. Your portion of the bill should be paid to the dental practice. If you have questions about the EOB, contact your insurance provider.