Introduction
Amerigroup is a well-known provider of Medicaid and Medicare health plans, offering a range of dental benefits to eligible members. While Amerigroup primarily works with in-network dental providers, some patients may need or prefer to visit an out-of-network dentist. This article explores what Amerigroup covers for dental services outside its network, eligibility criteria, reimbursement policies, and how to maximize your dental benefits when seeing an out-of-network provider.
Understanding Amerigroup Dental Coverage
Amerigroup provides dental benefits through various Medicaid and Medicare Advantage plans, which differ by state. These plans typically include:
- Preventive care (exams, cleanings, X-rays)
- Basic restorative services (fillings, extractions)
- Major procedures (root canals, crowns, dentures)
- Emergency dental care
However, coverage varies depending on whether a provider is in-network or out-of-network. Most Amerigroup plans encourage members to use in-network providers for the best coverage rates.
Does Amerigroup Cover Out-of-Network Dental Services?
Amerigroup generally does not cover out-of-network dental services unless:
- It is an emergency and no in-network provider is available
- The required treatment is not available within the network
- A specialist referral is approved by Amerigroup
- The plan includes an out-of-network benefit (varies by state and plan type)
Emergency Dental Services
If you experience a dental emergency, such as severe pain, infection, or injury, Amerigroup may cover out-of-network treatment. However, coverage is typically limited to pain relief and immediate stabilization rather than full restorative procedures.
Medically Necessary Procedures
For procedures deemed medically necessary that are unavailable within Amerigroup’s network, out-of-network coverage may be approved. This often requires pre-authorization from Amerigroup.
Reimbursement for Out-of-Network Services
If your Amerigroup plan offers out-of-network coverage, you may have to pay upfront and submit a claim for reimbursement. Reimbursement rates depend on:
- Plan type (Medicaid, Medicare Advantage, or private plan)
- Usual and customary charges (Amerigroup may reimburse only a percentage)
- State-specific policies
How to Check Your Amerigroup Dental Benefits
To determine whether Amerigroup covers out-of-network dental services for your specific plan:
1. Review Your Plan Documents
- Log in to your Amerigroup member portal
- Check your Evidence of Coverage (EOC)
- Look for details on out-of-network dental benefits
2. Contact Amerigroup Customer Service
- Call the Amerigroup Member Services number on your ID card
- Ask about out-of-network dental reimbursement policies
- Verify any prior authorization requirements
3. Speak with Your Dentist
- Ask if they are in-network with Amerigroup
- If out-of-network, discuss payment options and reimbursement policies
Out-of-Network vs. In-Network Dental Costs
Choosing an out-of-network provider often means higher out-of-pocket costs. Here’s how they compare:
| Service | In-Network Cost | Out-of-Network Cost |
|---|---|---|
| Routine Exam | Usually $0 | Partial reimbursement or full cost upfront |
| Cleaning | Usually $0 | May require out-of-pocket payment |
| X-rays | Covered | Reimbursement varies |
| Fillings | Partial coverage | Higher cost or no coverage |
| Root Canal | Covered with copay | Limited coverage or full cost upfront |
| Crowns | Partial coverage | Higher out-of-pocket costs |
| Dentures | Covered with pre-approval | Higher cost and possible limited reimbursement |
Steps to Get Reimbursed for Out-of-Network Dental Services
If you visit an out-of-network dentist and your Amerigroup plan allows reimbursement, follow these steps:
Step 1: Obtain an Itemized Invoice
Ask your dentist for a detailed bill that includes:
- Dentist’s name and contact details
- Date of service
- Procedure codes
- Total cost paid
Step 2: Fill Out an Amerigroup Claim Form
Most Amerigroup plans require members to submit a dental claim form for reimbursement. You can:
- Download the form from the Amerigroup website
- Request a copy from customer service
Step 3: Submit Your Claim
Send the completed claim form and invoice to Amerigroup via:
- Mail (address provided in your plan documents)
- Online submission (if available)
- Fax (if permitted)
Step 4: Track Your Reimbursement
- Check the status of your claim in your Amerigroup portal
- Call customer service for updates
- Expect reimbursement to take 4-6 weeks
Alternative Options if Amerigroup Doesn’t Cover Out-of-Network Dental Care
If Amerigroup does not cover your out-of-network dental visit, consider:
1. Enrolling in a Standalone Dental Plan
Some members choose to purchase a separate dental insurance plan that offers broader coverage for out-of-network dentists.
2. Using a Dental Discount Plan
Some dentists offer discount plans that reduce costs for patients without full insurance coverage.
3. Seeking Sliding Scale Clinics
Nonprofit and community dental clinics offer affordable services based on income.
4. Asking About Payment Plans
Many out-of-network dental offices allow monthly payment arrangements for uninsured treatments.
FAQs About Amerigroup Out-of-Network Dental Coverage
1. Does Amerigroup cover out-of-network dental visits?
Amerigroup typically does not cover out-of-network dental services except for emergency care or medically necessary procedures.
2. Will Amerigroup reimburse me for an out-of-network dentist?
Some plans allow partial reimbursement, but you must submit a claim and may receive a lower reimbursement rate.
3. How can I find an in-network Amerigroup dentist?
Check the Amerigroup provider directory on their website or call customer service for assistance.
4. What if there are no in-network dentists in my area?
If no in-network providers are available, Amerigroup may approve an out-of-network referral upon request.
5. Can I get emergency dental care from an out-of-network provider?
Yes, emergency dental services are typically covered even if the provider is out-of-network.
Conclusion
While Amerigroup primarily covers in-network dental services, there are situations where out-of-network coverage may apply, such as emergencies, referrals, or medically necessary procedures. However, out-of-network dental care often comes with higher costs and additional paperwork for reimbursement. To avoid unexpected expenses, always check your plan details, confirm coverage with Amerigroup, and explore alternative payment options if needed.
By understanding your Amerigroup dental benefits, you can make informed choices about your dental care while minimizing out-of-pocket expenses.
