734 Hartness Road, Statesville, NC 28677

UNDERSTANDING YOUR DENTAL INSURANCE

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We would like to share this information regarding your dental insurance.

Our practice is dedicated to providing the best in patient care possible and does not participate with any insurance contracts in order to ensure that we are providing quality care.

We choose to be insurance friendly by verifying your (your dependent’s eligibility), receiving information about your policy, such as frequency allowances for services, limitations, and exclusions, only to assist in determining out-of-pocket expenses to better prepare you financially. Please understand that we do our best to obtain accurate information, estimate out-of-pocket expenses and copayments with accuracy; however, we can not guarantee how an insurance company will process a claim until we receive payment. We do not allow insurance involvement to direct our course of treatment.

Under most circumstances, we will file your dental insurance on your behalf, and accept the assignment of benefits in lieu of full payment at the time of service. There are some insurance companies that will not provide our practice the assignment of benefits due to the out-of-network coverage limitations that are built into their policies. These insurance companies include but are not limited to BCBS NC or Delta Dental. If you have a policy under one of these companies, then we will expect payment in full at the time of service, and file a claim for your reimbursement. Or we will provide you with a completed claim form that you may submit yourself. The subscriber typically receives reimbursement within 10 business days.

If we are experiencing any difficulties in collecting from your insurance company for services rendered, or if a claim is over 90 days old. We may close out the claim and ask you for the balance in full and have you contact your insurance company.

Please understand that if you have double coverage, that never guarantees full coverage, and all deductibles along with copayment amounts will be collected at the time of service.

If you have private insurance as primary coverage and Medicaid coverage as secondary, please understand, Medicaid is the payor of last choice. You will be responsible for paying any deductible involved with your primary coverage or if Medicaid does not cover any after insurance balance, you may be balanced billed.

The insurance policy that you have chosen is a direct contract between you, your employer, and the insurance company itself. If you are self-insured, this policy is a contract between you and the insurance company. It is your responsibility to have a full understanding of your policy and understand that we do not have any direct responsibility or involvement with your contract.

Please contact our office directly should you have any questions or concerns regarding our policy regarding dental insurance. Please direct all questions regarding your policy to the insurance company, as they can best assist you with this.

I have read this policy and understand that I am ultimately responsible for the fees involved in my dental care.
(Parent if minor receiving treatment)
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