What is a missing tooth clause?

What is a missing tooth clause?

When your insurance policy has a provision in the contract with an effective date that includes a  missing tooth clause, the cost of replacing the tooth via the crown, denture, bridge, and implant falls  on the patient, and the policy will not cover the restoration and considered as a pre-existing  condition. 

As per the research, around 69% of adults have a missing tooth. The worst-case scenario is when  the provider has already fixed the tooth, following the claim submission procedure, and gets denied.  Here a patient has a hefty bill because the policy will not cover the replacement before the effective  date. 

The missing tooth clause also comes with a waiting period different for the different insurance  companies as long as five years. The waiting period is one of the limitations to consider, such as for  filing waiting period is for six months. When that is the case, the insurance companies do not pay  for the treatment. 

Do all policies plan offer a missing tooth clause? 
Most insurance policies offer a missing tooth clause, but not all do. Before undergoing any  treatment, it is best to research the plan and read the fine print to avoid this clause. While  researching, if you figure that your insurer has a missing tooth clause and you still want the  treatment, in that case, you can set up a predetermination. 

As per the American Dental Association, a predetermination is an estimate of who pays what for the  service. Predetermination arrangement gives you an idea to save, budget, or set up the payment  plan. 

What to look for in a dental insurance policy? 

  • A missing tooth clause terms and conditions help you evaluate whether the insurance carrier  covers the cost for replacing or restoring a missing tooth. The policy beneficiary with a plan of  missing tooth provision will not cover the cost and is an out-of-pocket expense.  
  • The waiting period before the dental insurance coverage starting date will help understand when  the insurance company covers any tooth replacement cost. 

Working out with Missing Tooth exclusion 
It is crucial to understand your dental coverage terms if you do not want to end up with the surprise  of a hefty bill. Before you instruct your dental provider to start the replacement or restoration  process, read the terms and conditions of the policy to get covered. It is advisable to ask for  estimation to see what tooth replacement will look like and cost and get a predetermination. 

Just because you have a dental insurance plan does not mean that they will cover the cost. So  contact your insurance company that they did not sneak the clause in there. 

Other financial options 
If your plan is not covering your tooth restoration, then you have a few aspects to look at: 

  • Find a new dental insurance plan that covers your replacement. 
  • Look for a dentist who can replace your tooth at a reduced price even if you have to pay. 
  • Find a referral service to get a dental discount plan on the missing tooth replacement cost.

Talk to a billing specialist to know more about dental procedures and codes and how to bill them: Request a free consultation

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