Question: I have a dental PPO plan through Anthem Blue Cross from my employer. Even though I have had it for a few years, this was the first time I used it for more than my free cleaning. About a month ago, I had some dental work that was rather costly. Now, I get an additional billing from my dentist, who stated that the insurance did not pay much for the full porcelain crown I got. However, my dental plan says they will pay half the crown cost. Calling the dental insurance company immediately, I was told that they do not cover that ADA code but will cover up to the UCR rate for covered crowns on noncovered crowns. It seemed like double talk to me. A crown is a crown! What do they mean by ADA code? Help me understand. 

Answer: ADA codes are the service code for each dental service. This code number does not change, and it lets everyone from the dental office, insurance company, and claims department know what dental service you have done. Although wording can vary, the code does not. There are many ADA codes for crowns. Here is a sample.

2740 Crown porcelain ceramic substrate

2783 Crown ¾ porcelain ceramic

2750 Crown-porcelain fused to high noble metal

2751 Crown-porcelain fused to predominantly base metal

2791 Crown-full cast predominantly base and

2810 Crown-3/4 cast metallic

There are more, but I listed a few to show you that a crown is not just a crown. Under many PPO plans may only provide benefits for a lower-cost crown, so when you get a higher-cost crown, they pay out only up to the UCR for the crown they cover. This offers you some savings, but now, it is as much as if you would have chosen a covered crown. One way to avoid billing surprises such as these is to have your dental office submit claims as a quote only to your insurance company before dental services are rendered. That way, you will know your cost ahead of time and can then decide if that is something you wish to continue with based on your budget.