Policy provision for reimbursement of dental services

by  Christine Taxin, President - Links2Success
May 25th, 2016

The law is as follows

“policy provision for reimbursement of dental services: payment regardless of discipline of provider: notwithstanding any provisions of a policy or contract of group health insurance hereafter delivered, issued for delivery, amended, renewed, or ratified whenever such a policy or contract providers for reimbursement for a service which within the lawful scope of practice of a duly licensed dentist, the following provisions shall apply:

A person covered under such group health policy or contract shall be entitled to reimbursement for such service regardless of whether the service is performed by a duly licensed physician or duly licensed dentist.”

Abstract

Many third-party payers try to deny benefits for dental sedation and general anesthesia. The term "not medically necessary" is often applied to these services by third-party payers. The label is poorly defined and varies from payer to payer. This paper uses original practitioner and patient opinion surveys to support the position that the definition of medical necessity is solely the joint responsibility of the patient and his/her physician. These surveys also support the argument that both patients and practitioners view dental sedation and general anesthesia as a medically necessary procedure if it allows a patient to complete a medically necessary surgical procedure that he/she might otherwise avoid.

1. G. Flick and S. Clayhold

University of Illinois College of Dentistry, Chicago, USA.

1. ANY traumatic injury to the mouth- all associated oral and dental procedures
2. Exams and consultations when oral cancer screening done, and in preparation for any other medically billable procedure
3. Emergency treatment of oral inflammation and oral infections
4. Diagnostic, radiographic, and surgical or healing stents
5. Radiographs for screening and diagnostic purposes (orthopantograms, occlusals, lateral jaw X-rays, Water's views, cephalograms, CT scans, tomograms, etc.). PA's and FMX are ONLY billable in conjunction with traumatic injuries.
6. Biopsies and excisions, including smears and brush biopsies
7. Extraction of all impacted teeth, also any extractions recommended by an MD prior to surgery, transplant, chemo/radiation, or due to a medical condition
8. Surgical procedures not associated with traumatic injury, including periodontal, reconstructive (implant), augmentation, soft and hard tissue grafts, etc. This includes the associated anesthesia.
9. Prosthetics- interim prostheses when surgery is involved, both interim and final prostheses if a traumatic injury or any medical condition necessitates their fabrication
10. Appliances fabricated for the treatment of bruxism, temporo-mandibular dysfunction, sleep apnea, snoring, palatal expansion, habit-breaking. Etc

What to do when the medical carrier should be involved.

First you must determine if the dental code you intend to use has a compatible medical code. Since not all dental codes (CDT) have a compatible medical code (CPT), proper coding guidelines are to use the CDT “D” code for submission if no CPT code exists.

The best way to determine if the CDT code has a compatible medical code is to cross reference with the CPT book, contact Links2Success for additional information for cross coding.

Dental offices that are providing services such as neuromuscular rehabilitation, implant surgery and oral surgery inevitably seek to bill their services to the patient’s medical insurance. Most of the services are reimbursable under the patient’s medical plan but you have to know how to fill out the right claim form, use the correct diagnostic codes and use the correct procedure codes.

Go thru your list of codes used last year and if you have codes that match what the University of Illinois College of Dentistry has used as their guide then contact Christine Taxin

www.links2success.biz

ctaxin@links2success.biz

ptaxin@links2success.biz

914-303-6464 Give us your referral from Jayme and we will offer you a ½ hour free consultation.