Insurance

At KOS we understand that insurance plans can be very confusing and challenging. We will make every effort to assist you in maximizing  your insurance reimbursement for covered procedures.

Dr. McDonald is a Participating Provider for many insurance carriers and networks, both medical and dental. As a participating provider we provide cost savings to our patients as they obtain in-network fees.

By providing our policy regarding insurance we promote good communication, enabling us to maintain a good doctor-patient relationship. Our policy is as follows:

  • It is your responsibility to know if a KOS doctor is in your plan.
  • If your parent/guardian is financially responsible for your account and/or is the insurance subscriber, they must accompany you to the initial consultation, regardless of your age.
  • A copy of current valid medical and dental insurance card(s) are required.
  • We will contact your insurance carrier to verbally verify eligibility and determine an estimated percentage of coverage. The difference between our fee and the estimated insurance percentage will be collected on the day of surgery. Verification of benefits is not a guarantee of payment.
  • Your insurance coverage is determined by the contract between you, possibly your employer, and the insurance carrier. We cannot control coverage decisions.
  • If you are a member of a managed care plan for which we are a provider, your co-payments and deductible are due at the time of service. If, for any reason, your insurance carrier denies coverage for your claim, you must pay for services rendered by this office at the regular fee-schedule rates.
  • Our fees are considered reasonable and customary by most insurance carriers and are covered up to the maximum allowable by those carriers. Occasionally insurance carriers will partially deny a claim on grounds that the fees are not reasonable. We have no control over these actions and cannot adjust our fees retroactively.
  • We will send you a monthly statement. Most insurance carriers will respond within 2 to 4 weeks after your claim has been filed. Please call your insurance carrier if your statement does not reflect your insurance payment within that time frame.
  • If your insurance carrier does not process your claim within 30 days, you will be billed directly for the full fee. In the event an appeal is necessary, we require payment in full of your remaining balance while the claim is being negotiated with your insurance carrier. If your insurance carrier pays an additional amount, we will send you a refund check after the additional payment is received.

PRE-DETERMINATIONS OF COVERAGE:

At your request, we will file a pre-determination claim to your insurance carrier to help verify your coverage before surgery. Results from pre-determinations may take anywhere from 4 to 6 weeks depending on your Insurance Carrier.

REFERRALS, IF REQUIRED BY INSURANCE CARRIER:

  • Referrals must be obtained by the Primary Care Physician, not your dentist.
  • Advance notice is needed for all non-emergency referrals, typically 3 to 5 business days.

MEDICARE (Coverage of dental services is very limited):

NON-COVERED EXPENSES BY MEDICARE:
  • Cleanings and fillings.
  • Tooth extractions and dental implants
  • Dentures or most other appliances/dental devices
COVERED EXPENSES BY MEDICARE:
  • Dental services that are an integral part of a covered procedure (e.g., reconstruction of the jaw following accidental injury).
  • Extractions in preparation for radiation treatment for neoplastic diseases involving the jaw(s).
  • Oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances.
  • Inpatient hospital services in connection with the provision of such dental services if the patient, because of his/her underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services.
  • Surgical procedures for the reconstruction of a ridge as the result of and at the same time as a tumor removal  (for other than dental purposes).
  • Payment for the wiring of teeth when it is done in connection with the reduction of a jaw fracture.
  • Dental splints if used in conjunction with the treatment of a covered medical condition (i.e., dislocated upper and/or lower joints).
  • Hospital stays if needed for emergency or complicated dental procedures, even when the dental care itself is not covered. Medicare makes payment for a covered dental procedure no matter where the service is performed. The hospitalization or non-hospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure.

MEDICAID:

KOS does not participate in Medicaid. Payment is due in full at the time of the visit.

REFUNDS:

  • Patient refunds will not be processed until all insurance processing is finalized.
  • Over payments will be refunded to the appropriate party within 30 days.
  • Refund(s) less than $5.00 will be issued upon request only.

Our Financial / Insurance Specialist(s) are well informed and here to assist you. Please call if you have any questions or concerns regarding your insurance coverage. We can be reached by phone at Kingwood Office Phone Number 281-358-2002.