Preventative vs. Basic vs. Major

on November 20, 2013

This week we will continue our dental insurance tips by explaining the different levels into which dental procedures are divided. To make sure you get the most out of your coverage, make sure you know the procedure you are receiving and where it belongs in the levels of service. We will be walking you through examples of each level and giving you examples of coverage breakdowns. Of course, every insurance has different breakdowns, so check with your insurance company to find out exactly how you are covered.

The three main levels of service are preventative, basic, and major.

  • At the preventative level, services that are covered usually include your prophylaxis (hygiene appointment), the doctor’s exam, bitewing and panoramic x-rays, fluoride application, and other dental preventative measures. Not all preventative measures are covered by all insurances. So although fluoride treatments are one of the best measures of prevention, your insurance may not cover it. Also, different insurances cover services at different frequencies. For example, a prophylaxis and exam may be covered twice a year OR every six months (usually to the exact day). Knowing your coverage frequencies can save you from having to pay out of pocket for having a service performed one day early.


  • At the basic level, services that are usually covered include composite resins (fillings or bondings) and some emergency x-rays and exams.


  • At the major level, services that are usually covered include onlays, inlays, crowns, bridges, dentures, and other full mouth procedures. Some insurance plans place a waiting period on these services. If you are looking for new insurance, check for a waiting period. You’ll be glad you did, especially if you have major treatment that needs to be done.

The coverage breakdown is, on average; 90-100% for preventative services, 80% for basic services, and 50% for major services. These percentages are of the insurance company’s usual and customary fees, not necessarily the office’s fees. If you visit an out-of-network provider, you will be responsible for the difference between what the insurance covers and what the office charges. The percentages provided here are just averages, contact your insurance company to find out your coverage breakdown.

If you ever have any questions as to how a service is going to be covered, we can send out a pre-treatment estimate to your insurance company. Or for a quicker response, you can call them directly and ask them. At Stephens Dentistry, we are happy to provide you with the ADA code that they will need to give you an estimate over the phone. Some insurance companies have automated their frequency limitation information, so you can find out how often you can have a procedure done without having to wait on hold.

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