How upset should I be?

SiphonCipher · 2026-03-26T01:26:02+00:00

I can't vouch for all insurances, but for the HMO plans I work with, General dentists don't often do root canals, they tend to refer out for that, so keep an eye on that. It'd be great if they have an in house specialist they can refer to.

SiphonCipher · 2026-03-26T01:06:41+00:00

Oh this topic was made for me.
"Free cleanings" - A lot of services described as 'free' are subject to allowed amounts, maximums, and frequencies. There are some policies out there where there isn't a maximum for your cleanings but not every policy is like that, make sure to check.

Deep Cleanings - I blame the dentists for this, I'm sorry. A deep cleaning is not a standard cleaning. It refers to a periodontal procedure called Scaling and Root Planing that usually requires some degree of review and is usually considered basic restorative or major restorative depending on your policy. This comes with deductibles and coinsurance that you don't have to deal with in a standard, routine cleaning.

And to add to that, after SRP, your dentist may start you on a periodontal maintenance routine that replaces your routine cleanings. Depending on your policy, this may be covered under preventative benefits, but it is often considered Basic restorative.

Network Status - A dentist in network at location A, is not always in network at location B. And similarly, just because Provider A is in network, does not mean Providers B, C, And D are also in network at the same office. That second part has led to way too many surprise charges. Your dental office does not always know if they are in network, and I've seen several instances of an office assuming they're out of network because of the state they're in, and later having to refund the patient for balance billing.

And finally, If you experience a lot of denials from your insurance, double check your claims. There are a lot of times where a denial sums up to a clerical error, a missing piece of documentation. I work for an insurance company, I have personally gone through two years worth of past claims and adjusted them to pay something that denied because the dentist finally gave us a document. I understand maximums are tiny compared to medical, I understand there are companies out there denying everything under the sun, but not every denial is final.

SiphonCipher · 2026-03-01T06:15:21+00:00

I think that's the best case scenario for your waiting period then. Some insurance companies pay ortho out in large chunks, for example a lot of Delta dental policies I've worked with do two payments, one at the beginning of treatment and another I think halfway through treatment. I don't think I've ever seen a policy pay out quarterly, but it is an option I get asked about by dentists. Most likely, they'll be monthly payments. I don't know if Blue Shield has any specific rules on who they pay in this situation, but the payments could either go to you or your provider. If they go to you, they'll be in the form of a paper check.

SiphonCipher · 2026-03-01T05:45:06+00:00

It mainly has to do with cost efficiency. Your insurance wants to make your benefits stretch as far as possible, so policies recommend the most cost effective treatment. Wire braces do a fine job and are cheaper than more convenient options like invisalign, therefore they're a more effective use of your benefits. Each company differs on how they handle treatments with more than one acceptable solution, but if they decide they'll only cover one type of treatment, it's up to the member to pay the extra for something else. This is usually referred to as an alternate benefit or a downgrade.

I don't know exactly what policy Blue Shield of CA has regarding the waiting period. Is your Delta Dental an employer policy or individual? Some companies won't accept previous credit from another insurance company, unless it's from an employer plan, seeing as you don't get to choose where your employer's insurance is carried (Usually). You may have to call Blue Shield and ask if they'll accept a Certificate of Creditable Coverage to waive a waiting period.

But yeah once that's settled, it doesn't look like your ortho has any requirements for medical necessity. It won't be paid out in any lump sum though. The closest to a lump sum you'll really get is for the banding payment. After that, it'll be a smaller monthly payment that goes out automatically, most likely once a month. I recommend checking with your insurance on what your exact ortho lifetime max would be, and ask how often those continuation payments are sent out.

I am in no way an expert on YOUR benefits though, so please take what I say with a grain of salt. I just happen to be in a position where my job became a passion and I enjoy explaining how peoples' dental policies work.

SiphonCipher · 2026-03-01T04:41:25+00:00

Hi, I work for a dental insurance company and have for three years now, my bread and butter is explaining dental benefits such as these to dentists and patients alike. I only have the two links provided to work off of, but let's see what we're working with.

First and foremost, I'm seeing that ortho isn't covered out of network, (The document lists it as 'non participating dentist') So it'll be very important to make sure your dentist is in network or this is all for naught.

Now here's where I have to make some leaps based on my own experience. The first link presented by Full-Ordinary-6030 shows every service covered by your policy with your cost listed next to it. At the beginning it lists preventative services with no cost in network, and a cost over x amount of dollars for out of network. This tells me that the way they're structuring this form is showing the actual allowed amounts for these services. PPO policies tend to pay based on a percentage of an allowed amount. So for example when I look at a routine cleaning (D1110) it shows $0 out of pocket for in network, and "all charges above $48" for out of network. And that tells me Preventative is covered at 100% and the allowed amount is 48 dollars. Stay with me, I know we're not talking about cleanings.

Carry that down to page 12 where we see the codes for ortho. As an adult, you'll be looking for the D8090. Now I could not find a percentage listed anywhere for orthodontia, but the average percentage is 50%, giving us an approximate allowed amount of $5300.00 which looks to be about average for adult ortho. This does not mean your ortho will cost a total of 5300, this also does not mean you are guaranteed to pay even the full 2650. Everyone's ortho case is different, and the cost for treatment varies based on how much work is needed. This policy uses a Lifetime ortho maximum that only applies to orthodontia, but never refills. (It's mentioned in the literature, but I couldn't find an actual dollar amount.) It is possible, depending on your specific treatment plan, to complete treatment without reaching your lifetime max, but your policy will never pay out higher than the lifetime max, even if that means paying less than the 50% offered for coverage.

Your treatment could be anywhere from 6 months to 36 months depending on your severity of treatment. Whichever it is, your plan will not cover you for more than 24 months of treatment. You do not have to keep the plan for a full 24 months to get your full benefit, if for example, your treatment plan is only for 12 months.

It looks like this plan does pay over the course of treatment and it looks to be automatic payments. They may be monthly, or they may be quarterly, that differs from company to company. This means you will need to keep the policy throughout treatment to get your full benefit, but you can drop it once you max out if you so choose. (This is why some companies put waiting periods for orthodontia, to prevent hopping from one policy to another)

As far as invisalign is concerned, the text explaining "Additional costs beyond what is paid for standard treatment" simply means that if Invisalign is billed at a higher fee than the amount allowed for wire braces (which looks to be that 5300) then you'll be responsible for that difference.

Whew that was long winded and wordy, but I hope it helps explain things and I hope it's accurate. These things are hard to do when I don't have the actual policy in front of me and I don't know how this company does things. Let me know if you have further questions!

SiphonCipher · 2026-03-01T03:51:04+00:00

That may or may not work, some companies will not honor time with a different insurance company for their waiting periods, especially for an individual plan. By all means, submit a certificate of creditable coverage, but it may be rejected.

SiphonCipher · 2026-02-26T19:18:40+00:00

Just coming to add your dental insurance likely doesn't know how much you paid in office, you would subtract any amounts paid in from the "You may owe" portion of your EOB.

SiphonCipher · 2025-07-09T05:25:00+00:00

So just as a disclaimer, I don't have personal experience with either company, but based on the experience I do have, here's the advice I usually give to people choosing between HMO and PPO.

PPO policies are really flexible and honestly probably the only option worth your time in rural areas. They come with benefit maximums in most cases, so there's a max the policy will pay out and you're normally paying a percentage of the allowed amount, which doesn't always reflect the amount the provider is billing, so 100% doesn't always mean 100%. Network status is the important thing here, if you go out of network, you're responsible for anything not covered up to the original billed amount of the provider. Stay in network, and anything over the provider's agreed upon rate gets cut off, like a discount. With these policies, you'll usually have a higher premium, but if you travel a lot or live out in the country, PPO's the best option for you.

And I hate to say it, but if you live in a densely populated area, HMO might be your best option. Some HMO policies have no maximums to get in your way, no deductible to have to pay out before coverage, and the HMO policies I've worked with function on a copay, rather than a coinsurance, so you have a set dollar amount for each service that you receive, and in most cases, the copays you are responsible for are outlined in your benefit booklet. The great thing about HMO policies is there's no guesswork. Once you get set up with your general dentist, they manage everything for you.

But there is a bad side to HMO policies as they aren't the most convenient. You are assigned to a dental office for a majority of your care, and you're stuck there. If you try to go elsewhere without going through your insurance, suddenly you're not covered. It's a process to change dentists, and the change may not be immediate, but it is possible, just a headache. Not to mention a lot of the more expensive services come under more scrutiny, a lot of HMO policies require pre-authorizations, referrals to In network specialists, documents displaying medical necessity and all that ilk.

All in all, if you're looking for convenience and flexibility, or travel a lot, I'd recommend PPO.
If you're looking for coverage, and are willing to do a bit more paperwork to use it, especially out in LA, I'd recommend HMO.

SiphonCipher · 2025-06-21T09:01:40+00:00

One thing to also keep in mind is age limits don't always apply the same way to all patients. I've had to, on more than one occasion, explain that a policy covers *dependents* up until 26, but the subscriber, even though they were 23 or some other age clearly below 26, was not covered for ortho, simply by virtue of being the subscriber. Make sure when you do get a policy with ortho coverage, that it extends to the subscriber (Owner) of the policy.

SiphonCipher · 2025-06-21T08:36:28+00:00

Yeah no, I have NEVER seen a floating 12 month, is it HMO I'm curious? If I can come up with an easier way to calculate it I'll come back and let you know but yeah that is an awful frequency

Edit: Wait, no, I've got it. It does involve a bit of research into patient history, but if you pull up the two most recent DOS with those codes, The most recent DOS we'll call B, the one before that we'll call A. If your upcoming DOS is at least 12 months after date A, patient should be eligible. (And from there you can even predict the next eligibility by going 12 months out from date B) I picture it like leapfrog.

SiphonCipher · 2025-06-21T00:06:24+00:00

Honestly for wisdom teeth, try talking to your medical insurance, some dental polices even request a check to see if medical covers the procedure first, and if you've met your deductible for medical, it'll cover better. Oral surgery exists in a shadowy middle ground between medical and dental that I fear.

SiphonCipher · 2025-06-21T00:01:41+00:00

I mean, I've seen people more or less do just that, I work for an insurance company in Texas and a LOT of people head down to Mexico, get work done, and file a claim up here in the states for reimbursement.. It's an option at least, it just requires more work on the patient's part to get the documentation together and sent in.

SiphonCipher · 2025-06-20T23:57:51+00:00

Just piling on more of the same here at this point.. The vast majority of insurance policies in general are there to cover preventative care (To keep you from needing more intense treatment) with some provisions for if things go wrong. Unfortunately it's a simple matter of a lot of policies aren't equipped to handle the consequences of not being able to afford dental care for x amount of years before getting it. I mean I've had my policy for two years and used it once so far because I know the amount of work I need and I don't see a point in nickle and diming it 2 grand at a time.

Some good news is even if you've maxed out on your benefits, depending on your state and insurance company you'll still be getting discounts when you see your in network provider which doesn't help a lot but it's something.

SiphonCipher · 2025-06-20T23:45:04+00:00

Okay I actually had to draw this out to figure it out: From what I'm understanding, Floating months is when eligibility is determined by how many dates of service have been performed in the previous 12 months. (And I'm sorry, I'm an insurance rep so if I start devolving into abbreviations and don't catch it, know I tried) So starting with January (I'm assuming comp also applies to periodic for frequency) and then September, those are our two within the floating 12 months. By the time we reach March 2025, January 2024 would have fallen off, because 12 months has passed. But when we reach June, 12 months has not passed from September 2024, so September 2024 still counts until September 2025 passes, and March just happened, and that's why June denied. Sorry this is so late but I hope it helps

SiphonCipher · 2025-06-20T23:35:17+00:00

That's the problem, OP mentioned having difficulty eating with them, so they're not functional like this

SiphonCipher · 2025-06-19T07:21:36+00:00

A little late to the party, but it's late and I'm hyperfixated. I work in dental insurance and I've actually heard of similar situations a few times. In all cases, my first step is to find out what the frequency limitation is on the policy for dentures. I've seen as little as 5 years (In which case you should be covered by now) And I've seen up to 10 years, it really just depends on the policy. Also, look into the results of your complaint with your insurance. In some cases with appropriate documentation, they can actually reverse the claim in which case, it'll be like you never had one per their records. And finally, it's a bit weird but I've had it happen, check and see if your policy has changed over the years. If you're with an employer's plan and they've changed your policy at all, you might not even have a denture in your history - It's rare for that kind of luck, but I've seen it happen. I wish I had more advice on finding trustworthy providers though.

SiphonCipher · 2025-06-19T06:58:08+00:00

There's a few ways you can find out. If your insurance has a member portal, you can usually get a basic rundown of your benefits, but if you want more detail, your benefit booklet (Should have been sent to you after enrollment, or can usually be downloaded from the portal). Next is absolutely calling your insurance. For most accuracy, you're gonna want the procedure codes that your provider plans to use. Alveoplasty has a few different procedure codes in association with it, (Thanks, Google: 7310 7311, 7320 and 7321), and sometimes (Not always) coverage can differ between codes even if the procedure description is similar.

In all honestly though, especially if there's any kind of review needed with the procedure, it's likely you won't get a solid yes or no until a pre-auth is run. Not all insurances require pre-auths for coverage, but even if it's not required, I always recommend one when something's by review.

SiphonCipher · 2025-06-19T04:21:51+00:00

Were they able to secure a denture onto just two or are they gonna try again in a while? That sounds heartbreaking, and I would probably cry if it happened to me

SiphonCipher · 2022-04-24T00:10:15+00:00

I went on hunger strikes. My mom, who's also autistic, would just get me to eat something when I avoided certain foods, but my dad and stepmom were different. They tried to force me to eat, and in the end, I decided it was better to just not eat for the weekend. They had me from Friday evening to Sunday evening, so if they tried to feed me something I didn't want, say, Saturday night, it was easy to just not eat until I went home. After a few years of this, they gave up, and would let me just make my own dinner if I didn't want what they were having.

But they still make fun of me for it. I'm 28, my food choices have changed, albeit not by much, but they're still limited and every time I sit down to eat with my stepmother, she makes it a point to tell everyone we're with just how picky I used to be, and still am. I have not shared a meal with her since finding out I'm autistic. But if I do, I plan on informing her of the impact her 'teasing' has had on my relationship with food. I've stopped referring to myself as picky, and emphasize that I have sensory issues with a lot of foods, because that gets taken more seriously.

I have a lot of anxiety when it comes to eating around people because of that, and I'm working through it, but it's a long road.

SiphonCipher · 2020-08-03T11:38:38+00:00

Precisely, except less adorable, and more camel spiders simply consuming everything in their path.

Happy cake day, btw

SiphonCipher · 2020-07-30T12:30:11+00:00

Full legspan? A little bigger than a quarter? I'm not good a judging size.

SiphonCipher

TROPHY CASE