How Dental Coordination of Benefits Works When You Have Two Insurance Plans

Having two dental insurance plans might sound like a dream - double the coverage, right? Well, not exactly. If you're in this situation and just received a confusing bill or explanation of benefits (EOB), you're not alone. The process of how two insurance plans work together, called coordination of benefits, can feel like a puzzle with missing pieces.

Let's walk through this together so you can understand what's happening with your dental claims.

What Is Coordination of Benefits?

When you have two dental insurance plans, they need to figure out how to split the bill fairly. This is called coordination of benefits, or COB for short.

The key principle is simple: your two insurance plans should work together to help cover your dental costs, but they shouldn't pay more than 100% of your treatment. In other words, you shouldn't profit from having two plans. Insurance companies have rules to prevent what they call "overinsurance."

Think of it like this: if you have a $1,000 dental procedure and two plans that each cover 50% of costs, they don't both pay $500. Instead, they coordinate to make sure the total coverage doesn't exceed what you'd get with just one plan.

How Does Your Primary and Secondary Plan Work?

When you have two plans, one is considered your primary insurance and the other is your secondary insurance.

Your primary plan processes your claim first and decides what it will pay. Then your secondary plan looks at what was approved and decides if it will help cover any remaining balance.

So which plan is primary? Usually it's determined by:

• Employment based coverage: If you and your spouse both have plans through your jobs, your plan is primary for you. Your spouse's plan would be primary for them.
• Age of the plan: Sometimes the plan you've had longer is primary.
• Coordination of Benefits rules: Both insurance companies follow specific guidelines outlined in their policy documents.

The secondary plan won't just automatically pay whatever the primary plan doesn't cover. Instead, it will look at what it would have paid if it were primary, then decide whether to chip in and bridge any gaps.

A Real Example

Let's say your dental cleaning costs $200. Here's how coordination typically works:

Primary Insurance Decision: Your primary plan covers cleanings at 100% (preventive care). It pays $200.

Secondary Insurance Decision: Your secondary plan also covers cleanings at 100%. However, since the primary plan already paid the full amount, there's nothing left for the secondary plan to pay. Your out-of-pocket cost is $0.

But what if the amounts are different?

Primary Insurance: Your primary plan covers only 50% of a crown that costs $1,000. It pays $500, leaving $500 as your responsibility.

Secondary Insurance: Your secondary plan covers 80% of crowns. It calculates what it would have paid if it were primary: $800 (80% of $1,000). Since the primary plan paid $500, the secondary plan might pay up to $300 more, bringing the total coverage to $800 - which is what it would have paid anyway if it were primary.

What Happens If You Get a Denial?

Sometimes you'll receive a denial notice from your secondary insurance saying it won't pay anything. This doesn't mean the claim is rejected - it usually just means the primary plan already covered the expenses fully or sufficiently, so there's nothing for the secondary plan to contribute.

However, if you see something that doesn't match your understanding, here's what to do:

1. Read the EOB carefully - Look for the explanation of why the secondary plan denied the claim. It should specify whether it's because the primary paid in full or another reason.

1. Check your primary insurance payment - Make sure the primary plan actually paid what the secondary plan received in their records. Sometimes there are processing delays.

1. Contact your secondary insurance - If something seems wrong, call them. Ask them to explain specifically why they denied the claim and what the primary plan paid.

1. Review your plan documents - Your COB rules might be spelled out in your plan documentation or summary of benefits.

What Should You Pay?

Here's the bottom line: you should never pay more than your out-of-pocket responsibility with one insurance plan.

If your primary plan has a $200 deductible and copay rules, you typically apply those same costs once. The secondary plan generally won't require you to pay a second deductible for the same service.

However, some complex situations can still result in confusing bills. That's where a second set of eyes helps.

We Can Help You Understand

Coordination of benefits gets complicated fast, especially when different plans have different rules and coverage levels. If you've received a bill or EOB that left you scratching your head, don't worry.

Have a dental bill you don't understand? Upload it to MyBillRx and we'll break it down for free. We'll review your primary and secondary insurance information, explain what each plan paid, and clarify exactly what you owe.