Introducing Dental Frequency Limits

Dental insurance plans are filled with limitations that don’t make a dental insurance biller’s job easy. There’s so much to remember when billing claims that it can be easy to get confused.  One common dental restriction is the frequency limit. In the following, we’ll introduce you to dental frequency limits and the treatments affected by them.  

What are dental frequency limits? 

Frequency limits are limitations to the frequency of certain dental procedures. These procedures can range from x-rays to exams to crowns. Many dental procedures are subject to frequency limits. The length of time they’re subject to varies from procedure to procedure. Once the frequency limit has been met, the insurance will no longer cover the treatment billed. 

Dental exams and consultations 

If a patient is on top of their treatment, they’ll be in the office twice yearly for their dental exam. If they have tooth pain or need to visit a specialist they may be in the office more frequently. When this occurs, remember that exams are subject to dental insurance frequency limits. Most plans will cover exams 2-3 times per year. Exams often share a frequency with consultations. If a patient has a dental exam and a specialist consultation, they will share a frequency. If their plan’s frequency limit is twice per year, it will have already been met. 

Dental x-rays

Frequency limits do apply to most x-rays but they vary according to the specific type. An FMX is usually covered once every 3-5 years, depending on the patient’s plan specifications. This same frequency also applies to panoramic x-rays. Bitewings are usually limited to a set amount per year. It varies from plan to plan but they’re typically covered 1-2 times per 12-month period. The only x-rays not generally subject to frequency limits are periapicals. 

Prophylaxis and perio maintenance 

Both prophylaxis and perio maintenance have frequency limits. These limits are often shared. Generally, prophylaxis is limited to 2 times per year. Periodontal maintenance is covered 2-4 times per year depending on the plan. Perio maintenance can only be billed after the patient has had either scaling and root planing or osseous surgery. There is often an 8-12 week frequency limit between the two. Under many plans, if the perio maintenance is billed within that time frame it will be denied for frequency. 

Fixed and removable prosthesis

Most prosthetics are subject to frequency limits. Dental fillings are covered once every 2 years.  Replacement crowns, bridges, dentures, inlays, and onlays are often subject to 5-10-year frequency limits. When billing replacements obtain the exact date of prior placement, as the insurance carrier will require this. Using a vague term like “over 5 years old” will cause the claim to be rejected with a request for a more specific date. 

As you can see, frequency limits apply to many different dental procedures. Dental frequency limits vary so greatly from treatment to treatment that it’s hard to keep track of all of them. Consider partnering with eAssist for your dental billing needs. Our Success Consultants are familiar with frequency limits and all their nuances. They will ensure your claims are billed correctly each time. Schedule a consultation here.