Understanding alternation of benefits

Learn about alternation of benefits and dental care.

Alternate benefits are less expensive treatments that still meet broadly accepted standards of dental practice. If more than one service or procedure can be used to treat the dental condition, the benefit is based on the treatment that is the most cost effective. The goal of alternation of benefits is to help keep premiums at a reasonable level for our members while providing coverage for necessary services.

Choice of treatment is between you and your dentist, so knowing your options is important. Your dentist should educate you regarding the risks, benefits and alternative options for a specific procedure. If you or your dentist should choose a more costly treatment or service, we will limit benefits paid to the alternate benefit. Any difference in cost between the alternate benefit and the charge actually incurred is your responsibility to pay, including any applicable coinsurance. Some intermediate and major services are automatically alternated to a less expensive treatment. These include:

Inlays (metallic, composite and porcelain) are alternated to a filling.
A prefabricated porcelain/ceramic crown is alternated to a prefabricated stainless steel crown.
Upper and lower complete and partial overdentures are alternated to upper and lower complete and partial dentures.

Other major and extensive services are reviewed by licensed dentists to determine alternate benefits. If it is determined that a service less costly than the one performed by your dentist could have been provided for you, we will pay benefits based on the less costly service. Examples include but are not limited to:

Implant services may be alternated to a partial or full denture.
A bridge may be alternated to a partial denture.

It is important that you speak with your dentist about treatment options for major or extensive services. You are responsible for the additional charges beyond the alternate benefit plan allowance.

Request a pretreatment estimate

Before you receive any major or extensive services, be sure to ask your dentist to submit a pretreatment estimate to BCBS FEP Dental. Doing so could help you avoid unexpected costs. It's important that pretreatment estimates include a comprehensive treatment plan and all of the supporting documentation, including chart notes, X-rays and photos. BCBS FEP Dental will provide a non-binding Explanation of Benefits (EOB) to both you and your dentist that will indicate what procedures are covered and an estimate of what we will pay for those specific services. The estimated plan allowance is based on your current eligibility and benefits in effect at the time of the pretreatment estimate. Submission of other claims or changes in eligibility or benefits may alter final payment. Keep in mind, a pretreatment estimate is not a guarantee of benefits.

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