The patient selects their dentist and receives treatment. If the patient pays the dentist directly, the employee submits a receipt for services to the claims administrator and receives reimbursement and an explanation of benefits. If the plan allows assignment of benefits, the dentist or patient submits the claim to the payer, and the dentist receives timely payment. The patient's portion is collected by the dentist at the time of treatment. The plan can be administered in-house or by a third party administrator for a fee.
Employers determine the annual maximum and reimbursement formula for expenses incurred.
The patient's financial responsibility varies depending upon their plan's copayment level and annual maximum. Because of its administrative simplicity, there is no need for pre-determinations, prior authorizations, or procedure based denials. Employees can easily understand the mechanics of this approach. The dental plan design limits the reimbursement amount through copayment levels and annual maximums. The plan can be designed so that the employee pays 10 percent to 40 percent of all charges.