What Factors Do Dental Insurers Consider Regarding Oral Surgery Procedures
Again, all coverage policies are dependent on your dental insurance providers list of exclusions and limitations. Most dental insurers factor in several common aspects of oral surgery treatment. This helps them determine if a situation fits within coverage guidelines.
For instance, your dental insurance carrier may ask the following:
- Is the dentist in or out of network? Insurance providers may consider a dentist in or out of their network. Often, the providers will cover more of the cost of an applicable procedure if it is performed by a dentist in network.
- Should treatment be covered under medical insurance instead?In some instances, oral surgery procedures may be covered by your medical insurance instead of your dental insurance. These are situations where treatment is deemed medical rather than dental. This happens frequently in cases of abscessed teeth. What occurs if your dental insurance provider feels that a treatment is medical? They will likely suggest you put a claim through your medical insurance provider for all or some of your treatment costs.
- Is the procedure necessary?If your insurance carrier believes that your oral surgery is elective, you may not receive coverage. However, this depends on the providers definition of elective services. Sometimes, the provider will ask for proof from the dentist that the oral surgery is necessary.
Can Dental Work Be Covered By Health Insurance
Health insurance providers are discerning. And for good reason.
Dental to medical cross-coding can cause administrative headaches and gridlock access to necessary dental services. All in all your patients medical plan will in many cases augment their dental benefits.
Keep in mind that dental insurance is more easily positioned to cover preventative treatment. Its essential to not raise red flags by trying to push through a procedure thats on the borderline for allowable dental or medical coverage.
Stay within the boundaries allowed by your patients dental coverage while being aware of what their medical plan will allow for dental procedures. The end result is helping assure that your patients have access to dental care.
Are Dental Implants Covered By Medical Plans
The big question patients ask Will health insurance cover implants? Dental implant costs are substantial. And for the primary reason that theyre restoring an essential tooth root.
Your patients oral health cannot be placed at risk by dental insurance companies and their denial of coverage for dental implants. In some instances, replacing a tooth root falls under what is allowable by a patients medical plan.
Its vital that you, as the dental provider, are specific in your examination and diagnosis regarding tooth replacement with implant treatment. Keep in mind that cut-and-dried cases where trauma or health related bone loss such as with certain cancers are easier for billing to your patients health insurance.
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How To Afford A Dental Implant Without Insurance
In the event that your dental and medical insurance dont cover dental implants or the portion that is covered leaves you with more to pay out of pocket than you can afford, dont let that prevent you from getting the procedure. There are some payment options to make the procedure more affordable.
- Establish a Payment Plan. Some oral surgeons will allow you to pay in installments, whether monthly or a portion of the total at each visit, knowing that a few visits may be required in order to complete the procedure
- Financing.Apply for financing so that you can make affordable monthly payments. CareCredit offers financing for medical/dental procedures with no interest for a certain period of time . Other loans are available through your financial institution that can be used to finance dental work.
- If you have a credit card with a high enough available limit, you can pay for the procedure using an existing credit card.
Is Oral Surgery A Medical Or A Dental Procedure
For the most part, the answer is that oral surgery is considered to be both a medical procedure and a dental procedure. While there are many types of oral surgeries that are performed specifically to help dental patients deal with and/or fix any medical problems they are currently experiencing, there are also many oral surgeries that are performed with a goal of specifically fixing dental-related problems.
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Is Oral Surgery Covered By Medical Or Dental Insurance
If youre planning a major oral surgery you may be wondering if its possible to get your medical insurance to cover your dental treatment. For people who dont have great or any dental insurance coverage, this can be a huge factor in whether its possible to move forward with your treatment.
The short answer to this question is that yes, medical insurance will cover some types of oral surgeries, but not all of them. In most cases, the two plans will overlap one another, picking up various aspects of the line-item expenses and expecting the other policy to pay for the ones that are not covered.
Who Decides if My Oral Surgery Falls Under Medical or Dental Benefits?
Your medical insurance and dental insurance claims are filed with specific codes used to describe the service that is being rendered. Codes outline the type of oral surgery, how complicated it is, which tooth is involved, anesthesia/sedation, etc. The insurance policy will then dictate which codes are or are not covered.
Once you have your written treatment plan in front of you, youll be able to see an estimate of which insurance plan pays for specific procedures and about how much will be left over for you to pay for out of pocket. Unfortunately, these are only estimates. Your dental or medical insurance may refuse to pay the claim, leaving you with the responsibility of covering that specific procedure.
When Sedation or Anesthesia is Involved
Why are You Having the Surgery?
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Major services like dental implants are covered
Pre-existing conditions, including missing teeth, will not be covered
Graduated annual maximums mean that low annual coverage limits can apply until the third year of coverage
Spirit Dental & Vision is an online storefront operated by Direct Benefits Inc., a major insurance provider. This coverage is underwritten by Ameritas Life Insurance Corp, which boasts an A rating from AM Best and an A+ rating from Standard & Poors for financial strength.
Spirit Dental & Vision offers coverage that includes dental implants as well as other major services. A dental insurance plan for an individual with $1,200 in coverage the first year, $2,500 in coverage the second year, and $5,000 in coverage the third year and beyond can start at $50 per month. All plans have an annual deductible of $100.
Spirit is also known for having coverage that doesnt require a waiting period, although coverage for implants doesnt apply to teeth that were missing already. Pricing varies depending on factors such as how many people are on your plan and where you live.
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What About Wisdom Tooth Extraction Or Dental Implants
Dental procedures are filed against insurance based on a series of codes used to describe them. Wisdom tooth extractions and dental implants are generally only included in dental codes and accepted by dental insurance, rather than a medical plan.
However, some overlap may exist. For instance, if you require a particular medical procedure or sedation in order to undergo a medically necessary dental procedure, there may be supporting data that allows your health benefits to include a portion of the treatment
Benefiting From Oral Surgery In Grapevine Tx
Whether some, most, or all of the costs of your oral surgery are covered, feel free to call us at 552-3223. That way, you can arrange for an initial, no-obligation consultation with Dr. Tye. Let us help you understand your financial responsibilities as a patient of Texas Oral Surgery Specialists. Contact our office today and start your journey to the smile you have always wanted.
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Do Medical Payors Reimburse For Dental Procedures
The good news is that, yes, medical insurance will cover dental work. Health insurance will give some latitude for a dentist billing medical insurance.
Dental plans are equally specific about the dental procedures it will specifically cover. Knowing the overlap points between health insurance and the details of a dental claim are key.
Reimbursement success will often come down to the insurance company, dates of service, and the dental care youre requesting payment for.
Dedicated Teams To Help Your Office With Oral Surgery Claims And Questions
Offering an Oral Surgery Center and specialized Oral and Maxillofacial Surgery Patient Management team are two ways we make doing business with us easier. The Oral Surgery Center is a specialized team equipped to handle all variations of oral surgery claims, including dental and medical.The Oral and Maxillofacial Surgery Patient Management team consists of board-certified oral and maxillofacial surgeons and nurses who are dedicated to the clinical review of certain surgical requests. In addition, this team provides precertification for oral and maxillofacial surgery and related services in accordance with the Aetna Medical Clinical Policy Bulletins.
To help make Aetna oral surgery benefits easier to administer, below are answers to some common questions.
How do I determine if a procedure is a Medical or Dental expense?
2. Determine in what Aetna plans your patient is enrolled.
3. Refer to this chart to determine if the procedure is covered and, if so, whether it is a medical expense or a dental expense.
The chart represents information for standard Aetna plans.
I participate in your dental but not your medical networks how will I be reimbursed if the procedure is covered under Aetna medical?Your dental rate will always be used to reimburse oral surgery services.
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What Does Dental Implant Insurance Typically Exclude
Dental insurance typically excludes procedures for cosmetic procedures such as teeth whitening and complicated oral surgeries that need to be handled in a hospital setting.
While the insurance plans we highlighted do cover dental implants, its important to consider how much this coverage will help. Many dental insurance plans have annual maximum limits of a few thousand dollars, which will only cover so much when youre planning a pricey dental implant procedure. Deductibles can also apply, as well as coinsurance or copayments that require you to pay more out-of-pocket outside of your monthly insurance premiums.
Many dental implant insurance policies wont pay for implants for teeth that are already missing when you sign up. In the same way that you cant buy homeowners insurance once your house is already on fire, you cant buy dental implant insurance for teeth that are already missing.
Oral Surgery For Medical Reasons
Many dental patients may be surprised to hear that any time they are diagnosed with inflammation or infection in their mouths that require oral surgery, they are treating a medical condition. Another example of treating a medical condition with oral surgery is when a dental patient is no longer able to eat due to tooth pain, as this directly interferes with their quality of life.
A shortlist of medical reasons that require dental patients to undergo oral surgery in order to correct them include having one or more impacted teeth, being diagnosed with bruxism, living with obstructive sleep apnea, experiencing cleft problems, facial trauma, corrective jaw surgery, head and neck cancers,
How Much Does Oral Surgery Cost With Medicare
As with any other type of procedure, the cost of your care depends on what you have done and what coverage you have.
Generally, however, you can expect to pay 20% of the total price as coinsurance. Medicare Part B has an average deductible of $203. The monthly cost of Medicare is $148.50 on average.
Additionally, if you dont have Medicare Part D, youll have to pay the total cost of any medication you are prescribed.
Dental Procedures Medical Insurance Might Pay
The better news is that theres a list of allowable procedures that your patients medical insurance will cover. Keep the following list handy to give them hope especially when they lack dental insurance, when their dental coverage has lapsed, or when their dental insurance maximums have been reached.
1. Exams for services that are covered by medical insurance
Be specific. And make sure about the procedures necessity.
2. Panorex X-Rays
These are more thorough and increase diagnostic success.
3. Oral infections, cysts, and oral inflammation
Infection and its impact can be sourced outside of the mouth in some instances. Be thorough in your diagnosis and willing to refer if medical billing is an option.
4. CBCT and Tomography
Another thorough diagnostic tool that helps source the deeper cause of a patients oral health issue.
5. TMJ appliances and headache treatment
The systemic nature of this treatment helps with medical billing. Be clear in your diagnostic language.
6. Sleep apnea appliances
Again, the systemic connection between the mouth, sinus, and breathing reflex helps categorize this as a medical condition.
7. Accidents to teeth
Mouth trauma can require medical diagnosis alongside your dental diagnosis and related care.
8. Mucosititis and stomatititis
The systemic impact of treatments outside the mouth can produce oral health issues requiring medical attention and related coverage.
9. Frenectomy for infants and children
10. Dental implants and bone grafts
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Tips For Choosing A Full
Keep these tips in mind when you shop for dental insurance:
- Estimate your future dental needs. Dont just think about the regular checkups and cleanings. Consider whether you or a family member will need major dental work or oral surgery.
- Find a plan your dentist accepts. If you like your current dentist, check to see if he or she is a member of that plans provider network.
- Consider your budget and how much you are comfortable paying. Decide whether youd prefer to pay monthly premiums, copays at the time of service or discounted fees directly to the dentist.
Only you can decide what full-coverage dental insurance means for you and your family. But with so many choices available, you can be sure to find a plan that works for you.
This material is provided for informational use only and should not be construed as medical advice or used in place of consulting a licensed medical professional. You should consult your doctor to determine what is right for you.
Humana is the brand name for plans, products and services provided by one or more of the subsidiaries and affiliate companies of Humana Inc. . Plans, products, and services are solely and only provided by one or more Humana Entities specified on the plan, product, or service contract, not Humana Inc. Not all plans, products, and services are available in each state.
Dental and vision plans, excluding Dental Savings Plus, may have a minimum one-year initial contract period.
Determining When Oral Surgery Is Medically Necessary
As you compare health insurance policies, you will discover that medical necessity is a recurring theme. Insurance will not simply pay for any type of oral procedure that you wish to have performed. You need to first demonstrate that your health and well-being would be adversely impacted if you do not have the surgery performed.
Consider wisdom teeth removal as an example. If you simply want to have these teeth removed because they are bothering you, but not causing any grave danger to your health, your insurance will not cover the surgery.
However, if the wisdom teeth have become impacted, this may result in grave health complications down the road. As such, with proper documentation, you will find that your health insurance provider is likely to pay out a benefit.
When making a determination of whether or not oral surgery is medically necessary, health insurance companies will look at a variety of factors. In considering wisdom teeth removal, here are some guidelines that you will want to follow.
These can be repeated for nearly any type of oral surgery that you are hoping to have covered under your health insurance policy.
As you can see, these situations are rather serious and would likely result in health insurance kicking in. While such surgeries may also be covered under dental insurance, it is not always financially viable to do so. Health insurance is much more comprehensive in nature and designed to help protect the overall health and well-being of the individual.
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D. Gilson is a writer and author of essays, poetry, and scholarship that explore the relationship between popular culture, literature, sexuality, and memoir. His latest book is Jesus Freak, with Will Stockton, part of Bloomsburys 33 1/3 Series. His other books include I Will Say This Exactly One Time and Crush. His first chapbook, Catch & Release, won the 2012 Robin Becker Prize from Seve…
Written byD. Gilson, PhD Professor & Published Author
Leslie Kasperowicz holds a BA in Social Sciences from the University of Winnipeg. She spent several years as a Farmers Insurance CSR, gaining a solid understanding of insurance products including home, life, auto, and commercial and working directly with insurance customers to understand their needs. She has since used that knowledge in her more than ten years as a writer, largely in the insuranc…
Farmers CSR for 4 Years
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