Medical and dental insurance are not on an equal footing. However, concerning what dental procedures are covered by medical insurance, only a small portion of unnecessary procedures are covered by dental insurance.
If certain conditions are met, dental procedures might be covered by medical insurance.
The majority of the time, this entails attending to a medical condition, recognizing a medical necessity, and using the appropriate medical codes.
Costs can be reduced by billing medical insurance, which is especially useful in these circumstances.
You should know what qualifies and how to improve your chances of the medical insurance approving the claim in order to do it successfully.
Dental and Medical Insurance Compared
The operation of dental insurance coverage is separate from any medical insurance you may have, and it typically uses a 100/80/50 coinsurance model.
When you meet the deductible and stay in the network, these plans pay 100% of preventative care, 80% of routine procedures, and 50% of major oral surgery.
Even though 50% is better than nothing, it’s not good news in emergency situations that have an impact on your general health. Your medical insurance plan will come into play in this situation.
After you’ve reached your deductible, medical insurance tends to cover a higher percentage of necessary procedures.
They can significantly affect the cost of major procedures and typically have higher annual maximums than dental coverage.
In contrast to dental plans, medical will only pay for the procedures in question if you’ve been injured or have a condition that is related to the procedures.
Some Dental Procedures that Medical Insurance May Cover
These examples may or may not be covered by someone’s insurance plan because medical insurance varies widely.
If at all possible, call the number on the back of your insurance card to speak with a representative about the details of your plan.
As you can see, most of these instances relate to medicine in one way or the other by:
- Diagnosing health issues
- Treating a problem through non-surgical means
- More invasive surgical treatment
- Addressing traumatic injuries in a timely fashion
Some procedures, like the removal of wisdom teeth, are done on an individual basis because they aren’t always required by medicine. Use this section as a general guide to what cheap medical insurance might cover.
1. Diagnostic Procedures
Exams, consultations, stents, x-rays, other scans, and basically anything else you might do to determine the cause of an issue are all considered diagnostic procedures.
These go beyond purely dental procedures like taking x-rays to find cavities and instead take a holistic approach to health.
Several instances include:
- CT scans and other medical imaging
- Head and neck evaluations (regarding orofacial medical issues)
- Clearance exams prior to chemotherapy or other surgeries
- Certain biopsies
- Panoramic x-rays
- CBCT and tomography
While these vary from routine checkups, your routine checkup may lead over into this territory.
2. Non-Surgical Medical Treatment
Medical insurance frequently pays for non-surgical medical treatments for orofacial conditions as well.
These therapies and treatments should enhance medical conditions and have documentation that they are not just for aesthetic purposes.
Several instances include:
- Sleep apnea devices
- TMD/TMJ appliances
- Treatment for facial pain
- Emergency infection or inflammation treatment, including drainage of abscesses
- Home fluoride trays (for patients going through cancer treatment
Although non-surgical procedures might initially seem less important, medical insurance should acknowledge their value in preventing future, more expensive, and invasive health issues.
3. Surgical Procedures
Surgical procedures seem like they would be simpler to explain as medically necessary procedures on the surface. Pre-authorization is advised if you rely on insurance to pay the bill due to the higher cost.
If you can connect some common oral surgeries to problems with your overall health, you might be covered. Others, such as dental implants, may be more challenging to present as a medical necessity as opposed to a cosmetic desire.
- (For younger patients; typically infants) frenectomy
- Occasionally extracting teeth and placing dental implants (if deemed medically necessary, typically in conjunction with replacing the tooth root)
- oral procedures to treat conditions other than dental ones
- Biopsies of tissue
- Increased sinus size
- Grafted bones
- Complex procedures (such as wisdom tooth extractions that go beyond a routine dental procedure)
- removing a cyst
If your dental insurance won’t pay for the surgery, keep in mind that some of the costs may be billed to your medical insurance.
A complicated wisdom tooth extraction is one instance in which the initial procedure may be covered by dental insurance while medical insurance covers the additional general anesthesia.
4. Traumatic Injury Treatment
Preauthorization is rarely useful in emergency situations, and insurance companies attempts to delegate responsibility are of little assistance.
When dealing with auto accidents, where this is especially frequent, you should bill the car insurance first.
the following additional injury sources:
- Sports and athletics (such as jogging, going to the gym, and leisure activities)
- Falling objects or other physical mishaps
- Natural catastrophes
Basically, this includes any time that physical harm occurs to your mouth.
Any restorative procedure, such as operations, implants, prosthodontics, and endodontic procedures, that is required to restore the appearance and functionality of your mouth to its prior state should be covered by medical insurance.
Dental Procedures that are NOT Covered by Medical Insurance
It can be simpler to comprehend what medical insurance does NOT cover.
This begins with routine dental care, such as biannual exams, preventive x-rays, cosmetic procedures (like tooth whitening), or the majority of preventative tooth extractions and root canals.
Most of these costs should be covered by dental insurance policies.
Any costs associated with auto accidents will also be passed along to the appropriate liability insurance by your medical insurance. Anything extra can then be charged to medical if necessary.
Requirements for Medical Insurance to Cover Dental Procedures
Simply put, the following conditions must be met for a dental procedure to be covered by medical insurance:
- Treat a health issue
- Possess evidence of medical necessity
- Have an associated medical coding
More so than the patient, the provider bears the burden of these conditions.
Patients can save a lot of money when they receive care at facilities that know how to bill medically for these procedures or when they use billing companies with the right expertise.
Treats a Medical Condition
If not the entire course of treatment for a medical condition, at least a dental procedure should be involved. Before moving on to surgical and non-surgical treatments, this may involve diagnostic procedures.
This relates to the next requirement, but keep in mind that the procedure’s purpose cannot be solely dental. There needs to be some awareness of how the symptoms or problem area affect various aspects of health.
Bonus points are awarded if it can be demonstrated that the dental procedure will stop problems that medical insurance will be solely responsible for in the future.
Because failure to receive proper, prompt care will snowball into a much larger issue, emergency treatments are almost always covered.
Only half of a medical condition can be treated. There should be medical necessity documentation for the procedure. Cheap health insurance providers use this somewhat ambiguous phrase, but it’s unclear exactly what “medical necessity” entails.
A more detailed explanation of what medical necessity means may be provided by your insurance policy or state of residence.
The National Association of Insurance Commissioners states that this typically refers to the “diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease”.
Treatment should not be a convenience but should be appropriate for the circumstance.
A “Letter of Medical Necessity” from your dentist might be required for your insurance company to consider. If the situation isn’t critical, you can request that your insurance determine medical necessity so there’s no guesswork involved.
Has a Corresponding Medical Code
The final section is more geared toward healthcare professionals than patients. As always, when billing insurance of any kind, you must use the correct codes. These codes specify information like:
- The challenging nature of the process
- The particular tooth or teeth in question
- Whether sedation or anesthesia is required
To determine what might or might not be covered, the codes are then compared to the policy. Unfortunately, dental and medical codes don’t function together in this context.
To get medical insurance to pay for a dental procedure, accurate medical cross-coding is necessary.
Even when there isn’t a suitable medical cross code, the CDT should still be fully disclosed to and taken into account. When submitting, use CMS 1500.
The patient’s medical records should also contain the necessary documentation of what brought them to the dental procedure if that was not the primary procedure performed in this case.
How to Secure Medical Insurance Cover for a Dental Procedure
Your chances of obtaining medical insurance to cover the costs increase as you learn more about your medical plan, your particular condition, and the dental procedure in question.
It is better to be over-prepared than under-prepared because a lack of documentation puts you at risk of having your claim denied.
When it’s feasible:
- Go over your insurance policy carefully with a comb.
- Ask your medical insurance for preauthorization before the procedure.
- Pick dental surgeons who have experience filing claims with medical insurance.
Although there is no assurance that your insurer will approve the claim, the more you do, the less likely it is that they will.
Understand Insurer Rules
Medical insurance is notoriously challenging to comprehend, and it doesn’t help that the policies vary depending on the circumstance.
You should receive a ton of documentation outlining the specifics of your plan, but it takes some effort to fully comprehend it.
Your coverage agreement and Summary of Benefits and Coverage (SBC) will be the most detailed records of what is covered.
The latter (which has a variety of names depending on the company) is a book that lists your benefits while the former is a general explanation of the cover.
The majority of businesses automatically provide digital copies, necessitating your request for a printed copy when necessary. Pick a presentation style that makes it simple for you to absorb the information.
Little actual explanation of the material covered is provided in the summary. Instead, you will have to read through the (possibly hundreds of pages) of information in your coverage agreement to determine what is covered and how much you are expected to pay.
If you’re using a digital version, you can use the search feature to locate the relevant step.
It’s frequently just simpler to contact your insurance provider and ask about the guidelines directly.
Make sure they comprehend the reason for your call, and instead of asking about a specific procedure, try to learn more about your company’s overall policy. Long-term, this will be beneficial to you.
Keep a record of your call, including who you called and when you spoke to them if you speak to someone.
This gives the final claim you submit to pay for your dental procedure more accountability.
You should have enough time to compile the evidence supporting the need for your procedure and consult with your insurance unless you’re in an urgent situation.
This prevents you from receiving a surprise bill and gives you time to carry out any additional diagnostics they may require in order to approve the claim.
The denial of prior authorization is not unusual. You can ask your medical insurance directly for an explanation, but your dentist will typically be able to provide one.
Don’t be afraid to let them know if you require a simple explanation.
Denial might force you to present more proof or try a different course of treatment first. You can reopen your appeal or make a fresh request and include the revised information.
Work With Dental Surgeon With Experience in this Area
Selecting a dental care facility with expertise in this field improves your chances of success and could hasten the procedures.
Additionally, dental offices that outsource to dental billing companies experience faster claim approval.
You benefit from working with someone who is knowledgeable about the industry-specific rules and procedures that govern the insurance sector.
How Much Does Dental Insurance Cost?
The average monthly cost of dental insurance in the United States is between $15 and $50.
You must consider both your dental habits and the type of plan you choose in order to decide whether dental insurance is worthwhile for you.
Remember to account for additional dental expenses like co-pays, co-insurance, deductibles, and annual caps.
Related: 4 ways to boost sales at your dental office
Additionally, you should carefully consider your likelihood of needing extensive dental work, as the cost can mount up quickly. It may be less expensive for people with healthy teeth to pay for routine dental care out of pocket.
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Your out-of-pocket expenses are reduced when you use medical insurance to pay for dental procedures, but the process is rarely simple.
For a successful outcome, getting the appropriate documentation and learning how to use the system is essential.
If you have questions about a particular procedure, keep in mind that it must be related to a situation involving your overall health and that there must be documentation of its medical necessity.
Pursue prior authorization whenever possible to reduce surprises and improve your chances of being accepted.
Please feel free to ask any additional questions you may have about using medical insurance to pay for dental procedures, either in the comments section below or by bringing the subject up with your practitioners.
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