What happens if I use a non-participating dentist?
You always have the option of going to a non-participating dentist; however, it will cost you significantly more money when you do. The examples below will show you the differences in payment levels between participating and non-participating dentists. You should also keep in mind that:
- You are expected to pay the difference between the non-participating dentist's full charge and Altus Dental's payment.
- You will probably have to pay the non-participating dentist first, and then file the claim with us, and we will reimburse you directly.
- You must ask the non-participating dentist to complete a standard American Dental Association claim form. Mail the completed form to:
Altus Dental Insurance Co., Inc.
P.O. Box 1557
Providence, RI 02901-1557
Before visiting your dentist, it is important that you find out if he or she participates with Altus Dental. Simply use our online directory or call your dentist to find out if he or she is a member of our plan. If your dentist does not participate with Altus Dental, click here to send us his or her name and address and we'll contact the office directly.
To learn more about the differences in payment levels between participating and non-participating dentists, please refer to your benefit summary, along with the following examples of how we would pay a non-participating dentist.
Please note: These are examples only. Actual charge and payment amounts will vary.
Example No. 1: Cleaning |
| 100% in-network - 80% out-of-network |
In-network (Participating Dentist) |
|
| Participating dentist's charge = |
$70.00 |
| Altus Dental Allowance = |
$60.00 |
| Altus Dental pays = |
$60.00 |
| Subscriber pays = |
$ 0.00 |
| |
(No Balance Billing) |
Out-of-network (Non-participating Dentist) |
|
| Non-participating dentist's charge = |
$70.00 |
Reasonable and customary charge for the area =
Minus deductible |
$65.00
-$25.00 |
| Altus Dental Pays: 80% of $40.00 = |
$32.00 |
Subscriber pays:
$70 minus the $32.00 Altus Dental payment = |
$38.00 |
Example No. 2: Amalgam Filling |
| 70% in-network - 56% out-of-network |
In-network (Participating Dentist) |
|
| Participating dentist's charge = |
$120.00 |
| Altus Dental Allowance = |
$100.00 |
| Altus Dental pays: 70% of $100.00 = |
$70.00 |
Subscriber pays:
$100.00 minus the $70.00 Altus Dental charge = |
+ $30.00 |
| Total payment to dentist = |
$100.00 |
Out-of-network (Non-participating Dentist) |
|
| Non-participating dentist's charge = |
$120.00 |
Reasonable and customary charge for the area =
Minus deductible |
$110.00
-$25.00 |
| Altus Dental Pays: 56% of $85.00 = |
$47.60 |
Subscriber pays:
$120.00 minus the $47.60 Altus Dental Payment = |
+ $72.40 |
| Total payment to dentist = |
$120.00 |
Example No. 3: Crown |
| 50% in-network - 40% out-of-network |
In-network (Participating Dentist) |
|
| Participating dentist's charge = |
$850.00 |
| Altus Dental Allowance = |
$750.00 |
| Altus Dental pays: 50% of $750.00 = |
$375.00 |
Subscriber pays:
$750.00 minus the $375.00 Altus Dental payment = |
+ $375.00 |
| Total payment to dentist = |
$750.00 |
Out-of-network (Non-participating Dentist) |
|
| Non-participating dentist's charge = |
$900.00 |
Reasonable and customary charge for the area =
Minus deductible |
$800.00
-$25.00 |
| Altus Dental Pays: 40% of $775.00 = |
$310.00 |
Subscriber pays:
$900.00 minus the $310.00 Altus Dental payment = |
+ $590.00 |
| Total payment to dentist = |
$900.00 |
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