Dental insurance plan rules explained in plain language

Out-of-network liability and balance billing

A network is a group of dental care providers who have agreed to accept a set rate for specific services when members of a dental insurance plan use their benefits. Providers within the network for a specific plan are also called “participating providers.” Your network choices may vary depending on your plan and where you live.

Out-of-network services are provided by dentists and other dental care professionals who have not contracted with your plan. A dental care professional who is out of your plan network can set a higher cost for a service than professionals who are in your dental plan network. Depending on the dental care professional, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing. In cases like these, you will be responsible for paying for what your plan does not cover. Balance billing may be waived for emergency services received at an out-of-network facility.

You can find a dentist who’s in your network here: Find a dentist

The amount you pay each month toward your dental insurance plan is called a “premium.” Premium payments are due on the first day of the month. 

If you are enrolled in a dental plan eligible for the federal healthcare advanced premium tax credit and we don’t receive your monthly premium payment by the due date, here is what will happen: Your plan’s grace period will begin on the first of that month and lasts for 90 days. Your coverage will end on the last day of your first unpaid month. For example, if your May premium is not paid by 90 days after May 1, we will only cover claims through the end of May.

We will pay all appropriate claims for services provided during the first month of the grace period for members receiving the federal healthcare advanced premium tax credit. We may “pend” claims for services provided to the enrollee in the second and third months of the grace period.

A claim that has been received but is still being processed is considered a pended claim.

If you are enrolled in a dental plan not eligible for the federal healthcare advanced premium tax credit and we don’t receive your monthly premium payment on time, your plan’s grace period will begin on the first day of that month and will last for 31 days. Your coverage will end on the last day of the last paid month. For example, if your May premium is not paid 31 days after May 1, we will only cover claims through the end of April.

If we pay for claims you made during a grace period, we will look to recover the payment(s).

We will look to recover the cost of any payment we made toward your claims if: 

• We overpaid  
• We paid for claims made during a grace period, but never received the overdue premium payment
• The claim was fraudulent

In most cases, your dentist will submit insurance claims for dental services to us on your behalf.

If you are asked to file a claim, please submit your itemized statement to the address on the back of your Humana member ID card. While a form is not required, 1 is available on the member document and forms page. Select the “Individual and family” tab to find it. 

Before you send us your claim, please ensure the following information is included:

• Name of the patient
• Date of the service
• Provider name 
• Provider Taxpayer Identification Number (TIN)
• Provider address
• Amount you were billed
• Description of the services provided
• Your Humana member ID number

Dental claims mailing address and phone number:

Humana Dental Claims
P.O. Box 14611
Lexington, KY 40512-4611
Customer Care department: 800-558-2813

All claims must be submitted within 15 months after you receive dental care. See your plan’s Proof of Loss period for details on the specific timeframe. Register with MyHumana to manage your benefits online, view your plan information and policies and get the most from your Humana dental insurance plan.

Register or Sign in to MyHumana to view your certificate/policy

If you have individual insurance (not through an employer) and overpaid for your monthly premium, we will apply the amount you overpaid as a credit toward your next premium bill. To request the overpayment as a refund, you may call the number on the back of your Humana member ID card. 

If you no longer have Humana benefits but overpaid on a previous bill, we will refund the premium within 14 business days if the payment was under $300. If the amount is over $300, the turnaround time will be longer. 

If you get insurance through your employer, and believe you’ve overpaid the premium and are due a refund, please contact your company’s health benefits administrator.

Preauthorization is not needed for dental care. However, if dental treatment is expected to be more than $300, you or your dentist may submit a proposed dental treatment plan prior to your treatment. We will use this plan to estimate if your dental benefits will cover the treatment. This is optional and not required.

The dental pre-treatment plan may include a(n):

• List of services to be performed, including any supporting documentation
• Written description from the dentist of the treatment
• Itemized list of costs

The estimate of dental benefits is not a guarantee of what we will pay. It tells you and your dentist in advance about the benefits that may be payable for the covered expenses in the pre-treatment plan.

We recommend having your provider electronically submit the pre-treatment request at least 14 before the scheduled date of service. The pre-treatment plan is valid for 90 days after the date we notify you and the provider of the benefits payable for the proposed treatment plan.

Under certain circumstances, we may deny a claim after the provider has already been paid. This is called “retroactive denial” and may occur if (among other reasons): 

• Your plan ended, but you received services before the provider was notified
• You received services before you paid your first month’s premium payment and never paid the overdue premium, so your plan never went into effect 
• The claim was found to be fraudulent
• Information submitted to us by your provider was incorrect  
• Payment was made for a duplicate claim
• Due to Coordination of Benefits* provisions
• You have other insurance coverage that paid benefits toward the claim

In cases of fraud, there is no time limit for a retroactive claim denial. 

For non-fraud cases, the time limit is typically 12 months from the time the claim was made but can vary by state. 

If we retroactively deny your claim for any reason, we will notify you via mail, email or your preferred contact method with an explanation. 

In certain cases, we may seek repayment from the care provider for a retroactively denied claim. If that happens, they may be able to bill you for the cost of the denied claim.

To avoid retroactive denial of a claim, you should: 

• Make sure that your premiums are paid on time.
• Review your provider’s billing statement to ensure the services you received are true and accurate. 

* Coordination of Benefits

If you have another insurance plan in addition to your Humana benefits, we may adjust your benefits so that the amount we pay toward a claim will not exceed 100% of the provider’s charge. 

Your plan’s Explanation of Benefits (SmartEOB) is an easy-to-read summary of any claims that were paid on your behalf. It also provides a snapshot of any year-to-date expenses we applied to your plan. 

After claims are processed, your EOBs will be provided via mail or electronically, depending on your communication preference.

Click here to see a sample SmartEOB and [CTA] click here and learn how to read and understand the information in your SmartEOB

If you have another insurance plan in addition to your Humana dental plan, we may adjust your benefits so the amount we pay toward a claim will not exceed 100% of the provider’s charge. We refer to this rule as Coordination of Benefits (COB).