By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"™
Patient Advocate, Certified Mediator
AdvimedPro
December 29, 2024
Are dental services or procedures covered under my medical policy? What are the exclusions and what are available benefits? Let's go through the list and see how best to use your medical policy for dental-related issues, injuries and conditions.
This blog only relates to Adults.
A. What is usually Excluded
1. Dental benefits are usually not covered under the medical benefits and are listed as
a specific "exclusion"
2. An "exclusion" is a specific service or supply specifically rejected from coverage, and therefore from payment by your insurance policy.
3. These services are specifically listed as "not covered":
· Preventive: dental exams, X rays, cleanings, fluoride treatments, specialist’s consultations.
· Diagnostic: X-rays to determine the extent and steps of the necessary treatment,
maybe even have some molds or models.
· Therapeutic: Do you need a tooth removed, restored or replaced? Not covered. Neither are crowns, root canals, implants or dentures.
· Considered cosmetic or non-essential: braces, mouth guards, whitening services,
snoring devices.
· Should you bite or chew, resulting in a broken tooth: that repair is not covered.
· Neither are dentures or services to fit them for a more comfortable wear.
B. What is usually covered
As everything in healthcare, there are exceptions to these exclusions:
1. Benefits are usually available for outpatient (rendered in a dental office or hospital setting) and for professional services (rendered by either a dentist or a doctor) for treatment of issues of the jaw bone, jaw joints or their adjacent tissues
2. Repair of cleft palate or any craniofacial anomaly is usually covered under the terms of your medical policy
3. Surgery to correct a deformity affecting the jawbone is usually a payable procedure, as are the treatments for an injury to the jaw or for an injury from chewing or biting (resulting from a specific medical or mental condition, not from biting on a nut).
4. General anesthesia should also be payable, as well as any necessary inpatient or outpatient facility charges if the member is developmentally disabled, or if a member's well-being and health could be compromised if general anesthesia were not administered.
5. TMJ is often a condition that brings up confusion. While both surgical and non-surgical treatments are usually covered, the extent of coverage for the associated services varies per policy.
6. Treatment of lesions, biopsies, removal of tumors, incision or drainage of an infection of a soft tissue in the mouth area are all usually considered medical conditions, and therefore payable.
7. Services necessary to prepare a mouth for a medical intervention, surgical intervention, transplant, or for treatment such as radiation, are also covered under your medical policy.
C. What to do:
1. Ask beforehand
Unless an emergency has arisen, I always recommend to get as much information beforehand as possible: from the dentist's office, from the medical provider (oral surgeon, financial counter surgery center or hospital, specialist’s billing person) and of course, from your insurance.
· What is the coverage for this particular procedure?
· Is it a covered benefit?
· Is my medical or dental policy going to be used?
· Will an anesthesiologist be involved?
· What is my expected total financial liability?
2. Get a pre authorization
· It will establish whether your medical or dental policy accepts responsibility.
· It will help confirm what services are covered and to what extent
· it will help estimate or even confirm your financial burden.
· In some States (CA for example) laws may guarantee a payment once an insurance has issued an authorization,
· It is up to the dentist or surgeon’s office to request that pre-authorization. Insist on it whenever possible.
3. Get it in writing
· This motto applies to the whole of the healthcare system: “if it is not written, it does not exist”
· An estimate of cost from the office will bring you not on peace of mind and establish the responsibility of provider and insurance, but also can guarantee that your rights are respected. It can also be used as evidence in case an appeal needs to be filed, if the information quoted by the insurance varies from the way the claim is finalized.
· I personally never signed up for any extensive dental or jaw related work until I have something in writing that gives me an indication of how much my share of cost might be, and some form of confirmation or guarantee that either my dental or medical policy are ready to step in and make payment.
The best way to find out whether a dental service or procedure is covered, and what your share of cost might be, remains through some advance work. A call or conversation with all parties can help minimize future bad surprises and let you focus on your full recovery.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2024 @ the medical bill whisperer 2024™
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