Every once in a while talking to a member we get the question "You didn't know that I was getting this treatment done?". Often it results in the member being short of appauld that the answer is "no". Which is true. As a dental plan, we do not know if what treatment you are getting done, when your treatment is being done or whether you are going to general dentist or a specialist. Why is that? The answer is simple.
Since we are membership dental plan and not dental insurance, there is no claim forms sent to us from the dentist. The saving to you as the member/patient is passed to you at the dental office. The dentist is agreeing to provide you treatment at our savings rate in return for us sending them patients.
A dental insurance company receives a claim form after each treatment, they review it and approve or deny the coverage of it. Then they pay the dentist their portion of the bill. So in essence, they are informed of every visit you make the to dentist office and what treatment they performed. As a dental plan, that is not the case.
In fact, the only ways that we would know that a member is going to the dentist is if the member informs us about it or if the dental center calls to verify eligibility. When the dental center calls to do that, the only thing we are at liberty to discuss is whether or not you are an active member. Due to HIPPA (Health Information Privacy Protection Act) they are not able to discuss your treatment with us, unless it requested by the member for them to do so.
For example, we can not call a dental center and discuss the treatment that you are having done. However, if you call us and have questions about your treatment plan or how much you are being charged, then we can call the dentist and discuss it because the request for our intervention was initiated by you.
So that's the reason why we don't know if you have visited a dentist or what treatment you are having done.
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