How to read a dental treatment estimate

The short answer

A dental treatment estimate lists the work your dentist suggests, the fee for each item and, if you have insurance, your share. To read it, find three numbers: the full fee, what the plan is expected to pay and what you are expected to pay.

The estimate is a plan, not a bill, and it is not a promise of payment. Your final cost can change if your coverage or your treatment changes. Here is how to read each part.

Steps 1 and 2: The treatments and the fee

Start with what the dentist wants to do. Each line is a treatment on a specific tooth or area. You might see a crown on tooth 14, a filling on tooth 3 and a cleaning for gum care. Teeth have numbers, from 1 to 32 in the usual system, so ask your dentist to show you which tooth each line means.

Next to each treatment you may see a short code. Dental offices use standard codes to bill insurance. They start with the letter D followed by four numbers. You do not need to learn them, but you can use them to compare offers from two offices, or to call your plan and ask about one specific line.

Each line has a fee. This is the office's full fee for that treatment. If your dentist is in your plan's network, the plan may set a lower amount that the dentist agreed to accept. The ADA calls this the plan allowance, or the allowed amount.

This matters. In-network, the dentist writes off the difference between the full fee and the allowed amount. Out-of-network, you may owe the difference. The ADA's guide to insurance statements lays out both cases.

Steps 3 and 4: What insurance pays and your share

Next you may see the insurance portion. It depends on three things: your plan's percent, your deductible and your yearly maximum.

Many plans pay 100% of preventive care, 80% of basic care and 50% of major care, once you meet your deductible. That is how Humana describes a common setup. So for a crown that is a major service, the plan may pay half of the allowed amount, and you pay the rest. If the plan has used part of its yearly maximum, it may pay less.

Also look for notes about waiting periods, and for rules that limit how often a service is paid. A line might say it is not covered this year, or that the plan will pay only a lower amount if there is a cheaper way to treat the tooth.

Last, the estimate shows what you owe. Add up the share from every line. That is your total. If you pay at the visit, you might also see a discount for paying in full. If you use a payment plan, you will see the monthly amount.

Check that the math makes sense. Take the full fee, subtract what insurance pays, and you should get your share. If the numbers do not add up, ask the office to explain.

A sample estimate with made-up numbers

Here is a simple example so you can see how the pieces fit. These are not real prices. Say the treatment plan lists one crown with a full fee of $1,400. Your plan's allowed amount for that crown is $1,100. Your plan pays 50% of major work, and you have already met your deductible.

Half of $1,100 is $550. The plan pays $550 and you pay $550. The $300 difference between the full fee and the allowed amount is written off if the dentist is in your network. If the dentist is out of network, you may owe that $300 too, for a total of $850.

Now add the yearly maximum. If the plan has only $400 left this year, it pays $400 and you pay $700 plus any out-of-network difference. If your dentist says it is safe to wait until the new plan year starts, the full benefit may be there again. Never wait on pain, swelling or infection. This is why it helps to ask what is left of your benefits.

Pre-treatment estimates are not a promise, and your explanation of benefits

For bigger work, your dentist can send the plan a request, called a predetermination or pre-treatment estimate. The plan answers with what it expects to pay. This is very helpful. It is also not a guarantee of payment. Delta Dental explains that things can change before the claim is paid: your coverage can end, your yearly maximum can be used up by other claims, and the estimate only reflects the plan's rules on the day it was issued.

So treat an estimate as a good guide. Ask the office to recheck your benefits close to your appointment date, especially near the end of the year or if you changed jobs.

After the plan processes a claim, it sends an explanation of benefits, or EOB. The ADA says an EOB should show the covered services, the plan's limits and any balance you owe. Look for these items:

• Plan allowance: the amount the plan sets for the service.
• Covered percent: the share the plan pays.
• Deductible applied: the amount you paid first.
• Amount paid: what the plan paid.
• Patient responsibility: what you owe the office.
• Remark codes: fine print that explains the decision.

What to do if numbers do not match

Compare your EOB with the estimate. Small differences can happen, because plans process claims at different times. If the difference is large, call the office first. Many mix-ups are simple to fix, like a wrong code or a missing deductible.

The ADA also notes that EOBs often use payer codes that are hard to read, and says to ask your office or plan to walk you through them. If the plan denies a claim you think is covered, you can ask for a written reason and appeal. Do it in writing, and do it soon. Keep copies of everything, including emails, letters and the names of people you speak with.

Estimates at KDA

At Kendall Dental Associates (KDA), we go over your treatment plan with you in plain words before we start, and we can help you understand what your insurance may pay. We accept most dental insurance plans, and financing is available. If something does not make sense, we want you to ask.

Call 305-271-1421 or visit 8833 SW 107th Ave, Miami, in the Kendall Mall. Our hours are Monday to Friday, 8:00 AM to 5:00 PM. Bring your insurance card, and a copy of any estimate you got elsewhere if you would like us to look it over.

Common questions

This article is general information, not medical advice. Your dentist will confirm what is right for you at your exam. General information checked against: ada.org, humana.com, consumerreports.org, deltadentalar.com.