How Out of Network Dental Insurance Works
Dental insurance language can make it difficult to predict what a plan will pay. Terms such as out of network, deductible, allowed amount, coinsurance, and annual maximum are frequently misunderstood.
Olive Tree Dental Care is not in network with any dental insurance plans. Full payment is required at the time of service. After treatment, our office submits a dental claim, and the insurance company sends any available reimbursement directly to the patient according to the plan’s out of network benefits and fee schedule.
Does out of network mean that nothing is covered?
Not necessarily.
Many PPO dental plans include benefits for treatment by an out of network dentist. However, the reimbursement may differ from what the plan pays when a patient visits an in network provider.
Some plans, including certain EPO or DHMO arrangements, may provide no benefit outside their network except in limited circumstances. Patients should verify the specific rules of their plan before treatment.
Why might patients choose an out of network dentist?
Dental insurance is only one factor when choosing a dentist. Patients may also consider:
The dentist’s treatment philosophy
Continuity with the same provider
Communication and personal attention
The available treatment options
Office technology
Location and scheduling
Comfort and trust
The ability to participate in treatment decisions
An out of network plan may still help reimburse part of the cost, but the patient is responsible for understanding the plan and paying the dental office’s full fee.
What determines the insurance reimbursement?
The amount paid by a dental plan may be affected by:
Whether the procedure is covered
The plan’s allowed amount or fee schedule
The percentage assigned to that category of service
The remaining deductible
The remaining annual maximum
Waiting periods
Frequency limitations
Alternate benefit provisions
Missing tooth clauses or other exclusions
Coordination with another dental plan
Whether required information or authorization was submitted
A plan stating that it pays a certain percentage does not necessarily mean it pays that percentage of the dentist’s full fee. The percentage may be applied to the insurance company’s allowed amount.
What is an allowed amount?
The allowed amount, sometimes called a plan allowance, is the amount the insurance company uses when calculating a benefit.
An out of network dentist is not contractually required to accept that amount as the full fee.
For example, imagine that a procedure fee is $1,000 and the insurance plan’s allowed amount is $700. If the plan pays 50 percent, it may calculate the benefit from $700 rather than from the full $1,000 fee.
The benefit could then be further reduced by the deductible, annual maximum, frequency limitations, or other plan provisions.
This example is for explanation only. Every plan processes claims according to its own contract.
What is a deductible?
A deductible is the amount a patient must pay before the plan begins paying benefits for certain services.
Some preventive services may not be subject to the deductible. Other categories may require the deductible to be satisfied first. The deductible usually resets according to the plan year.
What is an annual maximum?
The annual maximum is the most a dental plan will pay during its benefit year. It is not the maximum amount a patient can be charged.
Once the plan has paid its annual maximum, the patient is responsible for additional treatment costs for the remainder of that benefit period.
Claims from other dental offices may also reduce the amount remaining.
What is an Explanation of Benefits?
After processing a claim, the insurance company issues an Explanation of Benefits, commonly called an EOB. An EOB is not a bill. It explains how the claim was processed.
An EOB may show:
The procedure submitted
The dentist’s fee
The plan’s allowed amount
The deductible applied
The covered percentage
The benefit paid
The patient responsibility calculated by the plan
A limitation, exclusion, or denial code
For an out of network claim, the amount listed as patient responsibility may not always reflect the dental office’s full fee or financial policy.
If an EOB is unclear or appears incorrect, contact the insurance company using the telephone number on the insurance card.
Is an insurance estimate a guarantee?
No.
Eligibility checks and pretreatment estimates are based on information provided by the insurance company. They do not guarantee coverage or payment.
Benefits can be affected by:
Other claims processed before treatment
Changes in eligibility
Plan limitations
Missing information
Downgrades or alternate benefits
The final procedure performed
The insurance company’s review of the completed claim
The insurance company makes the final benefit determination.
What questions should you ask your insurance company?
Before treatment, consider asking:
Does my plan include out of network benefits?
Is this a PPO, EPO, DHMO, or another type of plan?
What is my remaining deductible?
What is my remaining annual maximum?
How does the plan determine its allowed amount?
What percentage applies to the proposed service?
Are there waiting periods or frequency limitations?
Does the procedure require prior authorization?
Are there alternate benefit provisions?
Will reimbursement be sent to me or to the dental office?
Write down the representative’s name, the date, and any call reference number. Ask whether the information is available through the insurance company’s online portal or in the plan document.
How insurance works at Olive Tree Dental Care
Olive Tree Dental Care is not in network with any dental insurance plans.
Our process is:
The patient pays the full fee at the time of service.
Our office submits the dental claim after treatment.
The insurance company processes the claim according to the patient’s plan.
Any available reimbursement is sent directly to the patient.
Our team can submit the claim and provide documentation required for normal claim processing. However, we cannot change the insurance company’s fee schedule, limitations, exclusions, or final benefit decision.
Planning for dental expenses
Before beginning treatment, patients receive information about the recommended care and estimated office fees.
Payment options include credit or debit card, cash, check, and Zelle when applicable. Financing is available here, subject to approval.
Learn more about our payment options and financing, or contact Olive Tree Dental Care at 941.732.0503 with questions about our office policy.
This article provides general educational information. It is not a guarantee of coverage or a description of any specific dental plan.
Reviewed for practice accuracy by Yuliya Kovalova, DMD
Updated August 2026
Sources
American Dental Association, Explanation of Benefits Statement
https://www.ada.org/resources/practice/dental-insurance/explanation-of-benefits-statement
American Dental Association, Dental Insurance 101
https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/practice/dental-insurance/ada_dental_insurance_101_ppo_plan_basics.pdf
