Finding out that Thrive isn’t in your insurance network can feel like a roadblock. It isn’t. If you have a PPO dental plan, you can almost certainly still be seen at Thrive — and in many cases your insurance will still cover a meaningful portion of your care. Here’s exactly how it works and what to expect.
Book your appointment at any of our six Dallas-area locations and we’ll verify your out-of-network benefits before you come in.
When a dental office is “out-of-network” with your insurance plan, it means we don’t have a pre-negotiated fee contract with your specific carrier. That changes how your benefits are calculated — but for most PPO plans, it doesn’t eliminate them.
Here’s the key distinction most patients don’t know: out-of-network is not the same as uncovered.
With a PPO dental plan, your insurance is designed to give you freedom of choice. Most PPO plans pay a percentage of your dental care costs regardless of whether your provider is in-network or not — the percentage is just typically lower out-of-network than in-network.
With an HMO or DHMO plan, out-of-network coverage is much more limited or may not exist at all. If you have an HMO plan, call us and we’ll help you figure out what options are available.
When you visit Thrive with out-of-network PPO coverage, here’s what typically happens:
Your plan pays based on “reasonable and customary” rates. Your insurance company sets a benchmark fee for each procedure — what they consider a fair market rate. They pay their coverage percentage of that benchmark, and you pay the difference between the benchmark and the actual fee, plus your coinsurance.
You may pay more upfront. Without a pre-negotiated fee agreement, you may be responsible for a larger portion of costs at the time of service compared to an in-network visit.
Reimbursement can go to you or to us. Depending on your plan, your insurance company may send reimbursement directly to Thrive, or they may mail a check to you. We’ll clarify how your specific plan handles this before treatment begins.
We submit claims on your behalf. Our team handles the claim paperwork for out-of-network benefits wherever possible — you shouldn’t have to navigate that process alone.
While every plan is different, out-of-network PPO coverage commonly follows this pattern:
Preventive care — cleanings, exams, and X-rays are often still covered at a reasonable percentage out-of-network, sometimes 60–80% of the plan’s reasonable and customary rate. Many plans don’t want to discourage preventive care regardless of network status.
Basic restorative care — fillings and simple extractions typically receive some out-of-network reimbursement after your deductible is met, though at a lower percentage than in-network.
Major restorative care — crowns, root canals, bridges, and implants carry the highest out-of-pocket risk out-of-network because costs are higher and coverage percentages are lowest. This is where the gap between in-network and out-of-network costs tends to be most significant.
Orthodontic benefits — braces and Invisalign orthodontic lifetime maximums often still apply out-of-network for PPO plans, though the applicable amount may differ. We verify orthodontic benefits at every free orthodontic consultation.
The only reliable way to know your specific out-of-network benefits is to let our team verify them before your appointment — which we do at no charge.
Patients choose to come to Thrive even when we’re out-of-network for a number of legitimate reasons:
Location and convenience. With six Dallas-area locations, we may be significantly closer to home or work than the nearest in-network provider. For a family making multiple dental and orthodontic visits per year, proximity matters.
Continuity of care. If you’ve been a Thrive patient and your insurance network changed at open enrollment, switching dentists disrupts your care history and relationships. Many patients find it worth a small additional out-of-pocket cost to stay with a team that already knows them.
Specialty services. If you’re pursuing Invisalign, veneers, dental implants, or other specific treatments, you may prefer a provider with particular expertise in those areas over whoever happens to be in-network.
Comfort and experience. Dental anxiety is real, and a practice where you feel safe and comfortable has genuine value. Switching to an unfamiliar in-network provider to save a small amount out-of-pocket isn’t always the right tradeoff.
We believe you should choose your dental home based on trust, quality, and fit — not solely on network status. We’ll always be transparent about what your out-of-network coverage means in dollar terms so you can make an informed decision.
Being out-of-network doesn’t mean paying full price with no help. Here are the strategies that reduce your costs:
Verify your benefits before your visit. Our team calls your insurance before your appointment to confirm your out-of-network coverage percentages, remaining deductible, and annual maximum. You’ll know your estimated out-of-pocket before you sit in the chair.
Request a pre-determination for major work. For crowns, root canals, or other major procedures, we can submit a pre-determination request to your insurance company. They’ll respond in writing with exactly what they’ll pay — eliminating surprises before treatment begins.
Use your FSA or HSA funds. Flexible Spending Accounts and Health Savings Accounts can be used for most dental services at Thrive regardless of network status. If you have an FSA, remember funds typically expire at year-end.
Pair with our Healthy Smiles Discount Plan. Our Healthy Smiles Discount Plan can work alongside your out-of-network insurance. Where your insurance falls short — services not covered, amounts above your annual maximum, or the gap between what insurance pays and what’s owed — the discount plan’s 20% savings apply. At $89/year, it often more than pays for itself.
Phase treatment across benefit years. If you need significant restorative work, timing treatment across two calendar years effectively doubles your available annual maximum. Our team helps patients plan this when it makes sense.
If your plan is an HMO (sometimes called DHMO), the rules are stricter. HMO plans generally require you to stay within a specific provider network, and out-of-network visits may receive little to no coverage.
If you’re not sure whether you have a PPO or HMO, check your insurance card — the plan type is usually listed. You can also call the member services number on the back.
If you have an HMO and want to see us at Thrive, your options typically include:
Our team is happy to help you think through your options when you call.
To make the benefits verification process as smooth as possible, bring:
If you book online, you can also call ahead with your insurance information and our team will begin the verification process before you arrive.
In most cases yes — especially with a PPO plan. Out-of-network doesn’t mean uncovered. Your plan will likely still pay a portion of your care, and our team will verify exactly how much before your visit so there are no surprises.
Yes. We submit claims on your behalf wherever possible and help you understand the reimbursement timeline. If your insurance sends reimbursement directly to you rather than to us, we’ll explain what to expect and walk you through the process.
Call us before your next appointment with your new insurance information. We’ll verify your out-of-network benefits and give you a clear picture of what your costs will look like going forward. Many patients decide the out-of-pocket difference is worth maintaining continuity of care — others need to weigh the costs. We’ll give you the honest numbers to make that decision.
We have options. Our Healthy Smiles Discount Plan can supplement your coverage at $89/year. In-house payment plans spread larger treatment costs into monthly installments. And for preventive care specifically, the out-of-network cost difference is usually small enough that most patients are surprised it’s not more. Call us and let’s figure it out together.
For most PPO plans, orthodontic lifetime maximums still apply out-of-network — though the applicable percentage may differ from in-network. We verify this at every free orthodontic consultation. HMO plans with orthodontic benefits may restrict coverage to in-network providers only.
Out-of-network doesn’t have to mean out of reach. Call us, give us your insurance information, and we’ll tell you exactly where you stand — before you commit to anything.
Find your nearest Thrive location — Allen, Frisco, Sachse, Richardson, North Dallas, or Dallas.
Conveniently located throughout the Dallas area to serve you better
Book your appointment today and experience the difference of premium dental care at an affordable price.
