Reviewed by a licensed dentistTopic: BillingQuestion: Balance billing
Can an in-network dentist charge me more than my plan allows?
The short answer
For covered services, usually not. An in-network dentist has generally agreed to accept the plan's allowed amount, so they usually can't bill you the difference. For services your plan doesn't cover at all, it depends on your state.
More detail
Four situations
- Covered and paid: you owe your share of the allowed amount, not the dentist's higher regular fee.
- Covered but not paid this time: because of your annual maximum, a frequency limit, a deductible, or a waiting period. The contracted fee usually still applies.
- Covered, but denied for not meeting the plan's criteria: it depends on your plan and the type of denial. See what you'll owe after a criteria denial.
- Not covered at all: in 44 states, the dentist can charge their regular fee. In Delaware, Hawaii, Massachusetts, Michigan, New York, and South Carolina, the network contract usually decides.
A useful test
Ask: would the plan have paid for this if the limit hadn't applied? If yes, it's “covered but not paid,” and the contracted fee usually applies.
Exceptions
These rules can vary from plan to plan, and state laws don't apply to every plan. If you're not sure which rules apply to yours, check your plan documents or call member services.
Out-of-network dentists
An out-of-network dentist hasn't agreed to your plan's fees and can bill you the difference between their fee and what the plan pays.
Questions to ask
- Is this service covered, excluded, or covered but not payable under my plan?
- Are you charging me the plan's contracted fee or your regular fee?