There are many different factors that go into calculating the reimbursement for a dental insurance claim. The specific treatments listed on the invoice, the dental plan you have, the length of time you've had the plan, and the severity factor for listed treatments are some of the most common reasons that may have led to your claim not being fully paid out.

Invoices for health services in Germany, dental services included, list something called a Steigerungsfaktor, or severity factor, for all the treatments listed. The factor is essentially a number rating the degree of difficulty or complexity for that part of the dental treatment. This number is assigned by a dentist or doctor, not by the insurance company. The higher the number, the more difficult the dentist is saying that part of the procedure was. Our dental plans reimburse dental services up to a factor of 3.5 - if any severity factors listed on an invoice are above 3.5, the extra amount is deducted from the reimbursement, resulting in an out-of-pocket expense. This is a very common reason for partial reimbursements.

Both our Basic and Advanced dental plans have yearly coverage limits for certain types of treatments that can lead to partial reimbursements.

During the first two calendar years, both plans provide a combined total of €300 (€150 for 1st year & €150 for 2nd year) for treatment related to the categories listed below:

Only after reaching your 3rd calendar year on the plan you can benefit from unlimited coverage towards the above treatment categories. Before then, if you have reached your limit, your reimbursement would be impacted.

In addition, Advanced plan has yearly limits for tooth replacement procedures.

The Advanced dental plan offers coverage for tooth replacement procedures (unlike the Basic plan), but depending on which tariff you have selected, your maximum reimbursement might not be 100%.

Not every single dental treatment offered by dentists is covered by our policies. The fee schedule of dentists (GOZ) contains a long list of possible dental treatments with the associated number. A dental invoice always lists the treatment and number - if that treatment is not covered by your dental plan, than the cost of the treatment will be deducted from the final reimbursement.

Common examples are items 4020 ('Local treatment of diseases of the oral mucosa, optionally including the rinsing of pockets, per session') and 4025 ('Subgingival local application of antibacterial medication, per drug') which sometimes dentists prescribe along with a cleaning. These types of treatments are not considered part of a routine cleaning and therefore not covered by our dental plans. In these cases you would receive a partial reimbursement and cover those costs out of your pocket.

These are some of the more common reasons for deductions. If you have looked at your invoice after reading this article, and still don't understand why you received a partial reimbursement, please contact our support team so we can help review the claim for you.