Insurance & Billing

At the Grand Traverse Smile Center we participate with the following Dental Insurance Companies: Met Life, Delta Dental, Dentemax and its Subsidiary Dental Networks including Blue Cross Blue Shield, and Lincoln Financial Group, and Guardian and its Subsidiary Dental Networks. We do not accept Medicaid but we do participate with the MI Child and Healthy Kids programs. For all other policies that we are not a participant we will courtesy bill your insurance company for you and collect from you only your co-payment amount for that service. With any insurance policy, it is your responsibility to review and understand what benefits and limitations are part of that policy. We can help you if you have questions but ultimately it is your policy and you need to understand it completely prior to consenting to any dental treatment in order to avoid any financial confusion.

We would like to take this opportunity to provide some general guidelines for insurance policies. Remember, your policy is exactly that, a contract between your insurance company and you. We bill your policy as a courtesy to our patients, however if they don’t pay a claim, it is the patients responsibility to pay our office accordingly. We have over 2,000 patients in our practice. It is impossible for us to know exactly what each employers plan will pay for each patient. Therefore, we recommend that you know your policy.

“Reasonable and customary” charges
This is a term made up by the insurance company, not a statement of fact on the pricing of Dr. Paulson’s services. Our fees have historically been at the midpoint of service fees for dentists in the Traverse City area. Your insurance company may put a limit on the amount they are willing to pay for a service. Unless you have a Delta Dental Premier policy, Dentemax and its subsidiary Dental Network including Blue Cross Blue Shield, Guardian and its subsidiary Dental Network or a Met Life policy, you are responsible for the difference between our fee charged and the fee the insurance company has arbitrarily set to pay for a service.

Policy limits
Dental policies will have annual limits that once a patient has reached, they will discontinue paying any further benefits. This includes preventative treatment; therefore if you’ve exhausted your policy for the current year, the policy will not pay for a cleaning even if they would normally pay 100% for that service. Also, we try to track benefits remaining for our patients; however policy limits can change from year to year. Also, if you have service completed at another providers office (including specialists), our system will not track those benefits used. It is your responsibility to know if you have benefits remaining prior to scheduling services.

Frequency and age limitations
This is a common cause of problems with patients and insurance coverage. Policies will often have the following frequency limit wording:

One time in six months (the service is paid once every 6 months, but not one day sooner)
Two times per calendar year (the service is paid for any date of service up to twice in a calendar year)
Two times in a twelve month period (the service is paid twice in a twelve month period, which may include looking back into the prior insurance year)

Policies may have different frequencies for various service types, so be careful to review each. A common difference is fluoride for children. Your policy may allow two cleanings in a calendar year, however only one fluoride treatment per year. Our standard of care for children is to apply two fluoride applications per year. Also, each policies fluoride treatments may have different age limits, meaning that once a child has reached a certain age (14, 16, 18 and 19 are the common ages used to stop paying), the insurance will no longer pay for fluoride.

Non preventative services may also have time limitations. Some common limitations (but not all inclusive):

Full series x-rays/panoramic x-rays are often limited to once per 3 or 5 years.
Fillings are usually limited to once per every two years on the same tooth.
Crowns are usually limited to one time per tooth every 5 years (but some policies use 7 and 10 years). Even if a crown breaks or you have new decay on the previous crowned tooth, if it is less than your frequency for that tooth, the insurance policy will not pay towards the crown benefit.

Missing tooth clauses
If you have a missing tooth and are looking at getting an implant or a bridge done, your policy may have a missing tooth clause, meaning if you had the extraction done prior to being covered on your current policy, they will not pay any benefits towards restoring that tooth. Preauthorization is recommended for these services.

Pre-authorization
Our office will pre-authorize services at no charge if a patient desires. This process can take up to 30 days to complete.

Fillings
This is the largest area of complaint that our patients have on their insurance coverage. Dr. Paulson’s practice uses composite fillings as the standard of care for fillings for all patients. 95%of insurance companies will only pay to have an amalgam filling (silver colored) on the rear molars. Therefore the patient may be responsible for 40-50% of the filling cost for each filling on the rear teeth if their policy covers “80% of fillings” in the summary policy description. Our fillings are priced based on the number of surfaces involved (this is how insurance companies pay) and are as follows:

One surface posterior $125
Two surface posterior $171
Three surface posterior $209
Four surface posterior $249

Dual coverage
Some patients will be covered under multiple policies due to both spouses having insurance coverage. The ordering rule of billing is normally done by billing your own policy first and the spouses’ policy second. For dependants, the policy holder with the first birth date is billed first. Some policies will have a “non-duplicatation” of benefits clause. This means that if a service that they would pay 50% for has already been paid for at 50% by the first insurance company billed, they will not pay any amounts towards the service. We have some patients where one spouse will get dual coverage and the other will not due to the ordering rule of the policies. Also, even with dual coverage, there may be some deductibles that are not covered.

In closing, we can’t emphasize enough that if money is a concern in your household, it is extremely important for you to understand your insurance policy. Our staff will try to assist you as much as possible, however if you want to be sure of what your policy will pay, we recommend a pre-authorization of benefits be sent in advance. Many policies will have on-line benefits and frequency limitations available to their policyholders on their websites. Also, their customer service departments can be called on the number available on your insurance card.