Dental accounts confuse a lot of people, mostly because the practice fee, the medical aid rate and your benefits are three different things. Here is how they fit together.
Three different numbers
- The practice fee: what the dentist charges for a procedure.
- The scheme rate: what your medical aid has decided it will pay for that procedure.
- Your benefit: how much of your plan is available for dentistry this year, often from savings or a set day-to-day limit.
Where co-payments come from
If the practice fee is higher than the scheme rate, the difference is a co-payment that you pay. You can also pay if your dental benefit or savings have run out, or if the treatment is not covered by your plan, as is common for cosmetic work like whitening.
Ask for a written quote
For anything beyond a check-up, ask for a written quote with the procedure codes and ICD-10 diagnosis codes on it. Your medical aid can then tell you exactly what it will pay, before the work is done.
Questions worth asking
- Does the practice submit claims directly, or do I pay and claim back?
- Is this treatment paid from savings, day-to-day benefits or risk?
- Does my plan need pre-authorisation for crowns, root canals or treatment under sedation?
- Are laboratory fees included in the quote?
At Marula Dental Studio we quote before treatment and submit claims directly to most schemes. Carla, our practice manager, is happy to help you check your benefits.
Need to see someone?
This guide is general information, not a diagnosis. For anything urgent, call 031 830 4471. We keep same-day slots free every weekday.