While most patients are covered by dental insurance for their treatment, it is important to note that insurance plans do not provide complete coverage for treatment rendered to patients.
There are portions that need to be paid by patients. There are also conditions, such as copayments and deductibles, that need to be met. Once these criteria are met, then reimbursement is made by the insurance company based on the dental insurance frequency limitations of the policy.
Insurance dental billing is not an easy task. There are codes that need to be accurately applied based on the treatment provided to the patient. There is another important element to consider while doing billing. Insurance plans come with dental insurance frequency limitations that make billing a little complex.
One of the restrictions while billing is the frequency limit. One needs to understand what dental frequency limits are and how treatment can be affected by them.
Dental insurance frequency limitations are primarily limitations on the frequency of specific procedures and services offered to patients.
Some of the procedures bound by limitations can include examinations, X-rays, and crowns. While a large volume of dental procedures can be restricted by frequency limits, the period can vary depending on the procedure. If the frequency limit for a treatment has been reached, then the treatment will not be covered by the insurance plan. Elements to be considered under frequency limitations are:
There is a possibility that a patient needs to undertake major dental treatment. The patient may have to visit a dental practice about twice a year for a dental exam. If suddenly, the patient has a recurring toothache, the visit to the dental practice would increase. One needs to keep in mind that exams are bound by frequency limits.
Most plans generally provide two or three exams every year. Usually, exams are also associated with consultations and can share the same frequency. If the practice assigns a dental exam as well as a specialist consultation, this will be counted as two. So, if the patient’s plan has a frequency of two per year, then the frequency limit of the plan would be complete for the year.
X-rays are covered by frequency limits across most plans. However, there can be varying rules based on the type of X-rays recommended. A patient’s policy might cover an FMX or panoramic X-rays once in three to five years, based on the plan specifications. The frequency limit for bitewings can vary from plan to plan and is usually set at once or twice a year. Periapical X-rays are not governed by frequency limits.
Frequency limits have a bearing on both prophylaxis and periodontal maintenance, and these frequency limits are usually shared. Insurance policies usually limit prophylaxis to
twice per year, while periodontal maintenance gets a frequency of two to four times a year. These limits would be based on the insurance plan of the patient.
Only when a patient has had scaling, root planing, or pocket reduction surgery can periodontal maintenance be billed. In terms of time interval, there is usually an eight to twelve-week frequency limit between the above two. In some plans, if periodical maintenance gets billed within that time frame, then it gets denied for frequency.
Prosthetics are impacted by frequency limits. A dental filling can be reimbursed once every two years. Frequency limits can be five to ten years for inlays, onlays, dentures, crowns, and bridges.
It is important to note that for billing replacements, the team needs to identify the exact date of the prior placement. The insurance company will ask for these details. A claim describing only five or six years old can lead to a possible denial. The team may need to resubmit with a specific date.
Clicking on a row in the Frequency Limitations Benefits grid is needed for frequency limitations for a Code Group.
In the Treatment Plan Module, the team needs to select ‘Estimates as of’ from the dropdown menu. A date needs to be selected for a treatment plan estimate to get updated and reflect the chosen date. If a procedure cannot be carried out on the selected date because of a frequency limitation, the same will be reflected in the procedure's description.
The team needs to double-click a procedure to view ‘Claim Procedures’ for more insurance estimate details.
Frequency limitation calculations can affect completed procedures that are attached to a claim and fall under the same insurance plan. Dates that have been entered in the ‘Insurance History’ by the dental team will also be considered. One needs to note that if any claim sent for submission is denied, or if a claim has been submitted but no reimbursement made, then frequency limitations will not be considered in such cases.
For understanding frequency limitations, an example using 3 can be considered. When 3 is entered in the # or Quantity box, the team can calculate or identify frequency options below:
A specific procedure can get covered by the insurance plan once every three years. The dental team can use the rolling year for calculation. A procedure done on 8/4/2025 will not be covered till 8/5/2028.
This means that a patient can utilise three procedures within the benefit year.
A procedure can get covered every three months.
Three procedures can get covered in the last 12-month period. This is calculated from a rolling year.
Many insurance plans have a cap on how many times in a year, month, or any frequency any specific procedure can get reimbursed under the provisions of the plan. Many plans limit the number of times the patient gets covered despite a recommendation by the dental practice. The dental team needs to understand how dental insurance frequency limitations work for any specific procedure and how they can impact the patient’s coverage. One must note that any decision must be made ultimately on what’s needed by the patient and not just the coverage guidelines of the plan.
