The Care that you Need...by People that you Trust.
J.Thomas Russell DDS
1030 Xenia Avenue,Yellow Springs, Ohio
Call: (937) 767-7731
How to Find the Right Dentist for You
When an organization which consists mainly of Attorneys (The US Congress) undertakes to reform the Medical and Dental Healthcare System, prudent persons need to understand:
- What coverage they have.
- What coverage they will lose.
- What coverage they will be able to add, and
- What it will cost.
Many folks don't want to be bothered by details and many folks are unpleasantly surprised to discover that they are not insured for the dental care they require.
Insurance companies love to collect premiums-it's how they make money. But they also can make money by creating policies that limit the benefits they pay out.
Your employer (in most cases) and the insurance company negotiated to arrive at the benefits you will receive. If you understand your dental insurance coverage, you will be in a better position to maximize your benefits.
I have listed, below, the schedule of benefits that might be in the majority of dental insurance plans. Use this to ask your insurance benefit info coordinator to fill in the blanks.
Once you have filled in the blanks, you'll be able to help your employer design the coverage you need, and understand the adequacy and value of your coverage.
You can download this file:
*all fields must be filled out to apply benefits to your treatment plan
Patient Name: ___________________ Subscriber Name: ___________________
Patient Date of Birth: _____________ Subscriber Date of Birth: _____________
Subscriber SS# or ID#: _______________
Subscriber’s Employer: ______________
Insurance Carrier: _______________ Group #: ____________
Claims Address: _______________________________________________________Payor ID #: _________________________
Phone Number: __________________
Coverage Rates: (if a “fee schedule” is in place, please attach)
- Diagnostic and Preventative _______ %
- Endodontic _______ %
- Periodontic _______ %
- Oral Surgery _______ %
- Fillings _______ %
- Crowns and Bridges _______ %
- Sealants (up to ____ years old) _______ %
- Deductible: $_______ Waived on Diagnostic/Preventative? Yeso Noo
- Annual Maximum: $_______ Calendar Year? Yeso Noo
- (if no, what month starts the benefit year? ____ )
- Benefits used to date this benefit year: $_________ Deductible met? Yeso Noo
- Do you reduce coverage to the amalgam rate for posterior composite fillings? Yeso Noo
- Do you pay crowns and bridges at the prep or seat date? _______
- Are there any waiting periods? (if so, please list) ___________________________________
- Is there a missing tooth clause? ___Yes oNo oCongenitally missing teeth only
- (D0210) Full Mouth Series of X-rays are covered every ______ years/months
- Date of service of the last full mouth series done for patient(s): __________
- (D0274) Bitewing X-rays covered every _______ months OR ____ times per year
- (D1110) Regular cleaning (called a “prophy”) covered every _____ months OR ______ times per year
- Fluoride covered every ______ months OR ____ times per year through age _______
- (D4910) Periodontal Maintenance covered every _____ months or ____ times per year
- (D4355) Full Mouth Debridement covered? Yeso Noo How often? ___________________________
- (D4341) Root Planing and Scaling: each quadrant covered every ______ months/years
Insurance Rep Name/Date: ___________________
Patient Signature: _________________________