Dental HMO vs PPO vs EPO
EPO vs HMO, and dental HMO vs PPO, is a difference of network, referrals, and payment: a dental HMO usually covers care only with an assigned dentist, a dental PPO pays the contracted fee in network and may still cover an out-of-network dentist, and an EPO covers in-network care without a typical HMO referral. Teero records the plan type and the breakdown in the PMS before the visit, as an add-on to Insurance Posting & Aging.
HMO vs PPO vs EPO for dental verification
Definitions for the person checking benefits. Coverage percentages are on the patient’s breakdown, not in this table.
| Topic | Dental HMO | Dental PPO | EPO |
|---|---|---|---|
| Network | Covered care is usually limited to dentists in a closed network. The patient often must see an assigned primary dentist. | The patient may see any dentist. In-network dentists have a contracted fee. An out-of-network dentist may still be a covered benefit, at the plan’s out-of-network allowance. | Covered care is limited to the exclusive network. An out-of-network dentist is generally not a covered benefit, except some emergencies. |
| Referrals | A specialist visit often needs a referral from the assigned dentist before the plan will pay. | A referral is usually not required to see an in-network specialist. Confirm the plan, because a few still ask for one. | An EPO usually does not require a referral to an in-network specialist. The dentist still has to be in the exclusive network. |
| Out of network | Out-of-network care is usually not covered, except some emergency treatment. The patient is often responsible for the full fee. | Out-of-network care may be covered at a lower allowance. The dentist can bill the patient the difference between the fee and that allowance. | Out-of-network care is generally not a covered benefit. Treat an EPO like a closed network on this point. |
| How the office is paid | Often a set copay schedule. Some dental HMOs also pay the office a monthly capitation amount. Confirm which one this plan uses. | A percentage of the contracted fee by category, after any deductible, up to the annual maximum. The percentages are on the breakdown. | Usually a contracted fee schedule for in-network care, closer to a PPO than to capitation. Confirm the schedule on the breakdown. |
| What to verify | That this office is the assigned provider, whether a referral is on file, and the copay for each planned code. | In network or out of network, remaining deductible, remaining annual maximum, waiting periods, and the category rules for the planned codes. | That this office is in the exclusive network before anyone promises coverage. Then the copay or coinsurance and the frequency limits. |
What to check before the visit
On Teero, eligibility checks are free and a full breakdown is $5. Teero writes the breakdown into the PMS through a PMS connection for Dentrix, Dentrix Ascend, Eaglesoft, Open Dental. Insurance verification is an add-on to Insurance Posting & Aging, under one $800 monthly minimum, with 12-month and month-to-month options available. Insurance Verification is sold only as an add-on to Insurance Posting & Aging; it is not sold on its own.
A worked Delta Dental example is on how to verify Delta Dental benefits. The product page is insurance verification. Posting the payment after the claim is Insurance Posting & Aging. Vyne Trellis, which also checks eligibility, is compared on Vyne Trellis alternatives.
