- An in-network dentist has contracted with your insurance company to provide dental services at a discounted rate to you.
- Dentists who contract with insurance companies often have their licenses and certifications confirmed.
- Dental PPO plans allow you to see both in-network and out-of-network dentists, but your insurance plan may pay a lower rate for out-of-network dentists. DHMO plans do not provide coverage for out-of-network dentists.
Even if you’re already enrolled in a dental insurance plan, the dentist you choose to visit can have a major impact on what you'll pay out-of-pocket. And if you’re currently shopping around for a dental insurance plan, choosing an insurance provider with a large network can make the difference between having multiple network dentists near you and having to drive clear across town to save money.
Knowing the difference between which dentists are in-network and which are out of network can help save you money and reduce paperwork.
An in-network dentist is a dentist who has contracted with your insurance company to provide dental services. You will typically pay less out of your own pocket when you receive care from in-network providers.
Insurance companies work with dentists all over the United States to help provide as many options for their policyholders as possible. The companies ask dentists to sign a contract agreeing to provide a certain discount for the fees for dental services to the company’s policyholders. Some agreements are for a certain percentage of fees; other contracts may require a flat-fee guarantee. Whatever form the contract takes, the dentist and the insurance company work together to make sure you get affordable dental services and the lowest fees possible.
In return for discounted fees, dentists in your insurance provider’s network become the preferred providers for all the company’s policyholders. This helps the dentist gain more regular patients who return again and again for dental services. A win-win-win for you, your dentist, and your insurance company.
Looking for a dentist within the Guardian Direct® dental network? Find an in-network dentist here.
What is an out-of-network dentist?
An out-of-network dentist is a dentist who is not contracted to provide services under your insurance plan. You will typically pay more out of your own pocket for services at an out-of-network dental office.
Some dentists may join a network if their patients ask. If you change dental insurance plans and you do not see your dentist listed in the network, do not hesitate to discuss the problem with your dentist.
When evaluating a new dental insurance plan, find out if you are restricted to only seeing in-network dentists. Dental preferred provider organization (PPO) plans typically allow you to see both PPO network dentists and out-of-network dentists, but your insurance company may pay a lower rate for out-of-network dentists and you will typically be responsible for the difference. Dental health maintenance organization (DHMO) plans do not provide coverage for out-of-network dentists.
Why should I go to an in-network dentist?
The benefits of visiting an in-network dentist instead of an out-of-network dentist go beyond just saving money. Here are a few common considerations of why it is recommended you visit an in-network dentist:
Less hassle for you
In-network dentists have a relationship with your insurance company. They understand their forms and codes and typically are comfortable filing claims on behalf of the patient. Your insurance company sends payments directly to the dentist, and you’ll receive a notice showing how much the dentist charged for services, how much the plan paid, and the amount of any remaining copays or deductibles. Since the in-network dentist may take on the responsibility of filing all bills, claims, and paperwork, you as the patient are relieved of those headaches.
Many patients and dentists like to get a pre-treatment estimate from insurance companies before starting expensive, complex dental procedures. In-network dentists have this process in place and can easily provide all necessary X-rays, test results, and paperwork. An out-of-network office may not be willing or able to provide this service for you.
Dentists who contract with insurance companies undergo a process known as credentialing. This is a process in which representatives of the insurance company vet and verify the dentist’s licenses, specialty certifications, malpractice insurance, and status with state regulatory boards¹. This can assure you that the dentist in-network meets strict standards and is in good standing with the professional community.
This is a process by which insurance companies monitor the treatment patterns of their in-network dentists. Utilization review examines the distribution of treatment procedures based on claims information, taking into account the type of practice, the dentist’s experience, socioeconomic characteristics, and geographic location². This can allow the insurance company to evaluate the dentist for practicing within the acceptable standard of care found in other dental practices in the community. Using an in-network dentist can give you confidence that the in-network dentist is not over-treating or under-treating, using unproven treatments, or performing services outside the norms of standard dental practice. If, for example, a dentist is billing the insurance company for an extraordinary number of crowns, far more than other dentists in the area, the insurance company may investigate. If they find that the dentist is over-treating, they may be dropped from the plan’s list of providers.
Usual and customary fees
Insurance companies determine the fees that are reasonable for that service in your community. Typically, they compare claims filed and keep a database of dental services and the normal fees associated with that service in various geographic areas. This helps the insurance company keep track of and update their allowed charges for a variety of dental services. Their allowed charge is the amount a company will pay for a dental service. For in-network dentists, this charge is based on their contract. Credentialed dentists are bound to the insurance company’s contract to follow their fee schedules and charge certain prices to the patient³. Out-of-network dentists are typically not bound by allowable charge limitations. To ensure you are not charged more than is usual and customary for your area, use an in-network dentist whenever possible.
What happens if I go to an out-of-network dentist?
Some people opt to use an out-of-network dentist due to an urgent need for care or because their trusted dentist is not a member of their plan’s network.
Because out-of-network dentists have not signed a contract to provide care to plan members at a discounted rate, you may pay more for services. Increased fees might not be enough to cause you to switch dentists, but if cost is your top priority, stick with a dentist who participates in your insurance plan’s network.
Occasionally, your in-network dentist may need to refer you to a specialist for complex care, such as oral surgery, implants, braces, or root canals. When this happens, ask if there is an in-network specialist who can provide your treatment.
Some out-of-network dentists may file claims on your behalf, depending on the type of insurance you have. Most will typically file claims for you if you have traditional dental insurance or a dental PPO plan. However, out-of-network dentists do not have a relationship with the insurance provider or a representative of the company to reach out to when questions arise or to assist with claim denials. If you have a DHMO plan, you may have to pay in full at the time of service at out-of-network dental offices.
How to find an in-network dentist near me
Most dental insurance companies provide easy access to lists of dentists in your area who are members of their network. You can usually find these on company websites or in written materials sent to you annually from the insurance company.
If you haven’t selected a plan yet, it’s a good idea to verify that an insurance provider has in-network dentists near your home or work in addition to verifying that plan premiums and out-of-pocket costs are within your budget. Take the time to investigate the network providers and see if you can find one that best suits the needs of you and your family.
Guardian Direct has a wide network of over 100,000 dentists, including specialists such as orthodontists and endodontists. If you have or are considering purchasing a plan from Guardian Direct, click here to find a dentist in your network.
Once you have selected a network dentist, call their office to confirm that they are still under contract with the insurance company. It may save confusion and stress to verify that the dentist is still participating in the plan before you make an appointment.
PPO Network Dentist – Insights
If you have a dental PPO plan, you may be able to receive partial coverage even if you visit an out-of-network dentist. But more often than not, you still may be able to enjoy the most savings by visiting an in-network dentist.
Visiting an in-network dentist can help you save money. We've compiled a list of resources to help you learn more about how to help reduce the cost of dental treatment and take good care of your smile.
How much should you expect to pay for dental insurance? Learn how much dental insurance costs.
Dental PPO plans allow you to visit nearly any dentist and still receive full or partial coverage. Learn more about dental PPO plans.
If your employer doesn’t provide dental benefits, you can get dental insurance from an insurance provider. Learn how to get individual dental insurance.
Wondering whether dental insurance covers cleanings, fillings, and other common dental procedures? Learn what dental insurance covers.
Ready to shop for a dental insurance plan? Start the process here.
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https://dentalbilling.com/what-is-dental-credentialing/, accessed June 2021
https://www.ada.org/en/publications/cdt/glossary-of-dental-administrative-terms, accessed June 2021
https://dentalbilling.com/what-is-dental-credentialing/, accessed June 2021
Brought to you by The Guardian Life Insurance Company of America (Guardian), New York, NY. Material discussed is meant for general illustration and/or informational purposes only and it is not to be construed as tax, legal, investment or medical advice.(exp.10/22)