Hey all, first time post in this group.
So far, I was able to find a user that had a similar instance with this and was able to get her insurance to cover it. I have had TMJ issues for nearly 15 years and have never had an issue with my medical insurance covering services for two other TMJ providers and Oral Maxillofacial Surgery/Hospital Dental Clinic at UofM, which all would not touch my jaw or stated that I was not a surgical candidate. This TMJ provider, I felt was my last resort before looking at the Mayo Clinic which is not near me. Now, this TMJ provider was very upfront about insurance most likely not covering a chuck of the services but that I would have to pay up front and then they would bill insurance after.
In my first appointment aka Data Collection appointment, I had to pay $695 up front. I then went forth with paying $3000 that day to get the ball rolling on my treatment that is medically necessary and that I needed. With not having any issues in the past with insurance coverage, I didn’t think that it would be flat out denied. So I ended up canceling my follow up appointments to receive my orthopedic appliances due to not having the other portion ($2000) to pay for the remaining bill. When I called to cancel that appointment because I was still waiting to hear back from my insurance company, the “billing” person in this office didn’t sound like they are willing to resubmit my claim to insurance and said that when I was ready to complete the treatment to call them back. Also, googling this office they have a handful of bad reviews specifically due to this same issue but more positive reviews.
My denial specifically stated that is was denied for: Dental services such as dental x-rays and dental evaluation/work-up are not covered. After review of the information submitted, the Complex Radiologic Exam (X-Ray), joint imaging, and dental work-up are considered a dental service and are not covered. Therefore, the requested imaging and evaluation are denied.
My next step that I did was pulled the Medical Policy for Temporomandibular Joint Disorders, reached out to insurance company inquiring about what ICD-10-CM & CPT codes were used in the claim, requested an appeal with insurance company and requested an external review with The State of Michigan and typed up an email to office to request them to resubmit the claim. That email is below:
Hello,
The information below is to be utilized to resubmit my insurance claim for my 5/10/2021 data collection appointment for my TMJD that was denied by my insurance. I have attached both the letter of denial and Priority Health’s TMJD policy.
I would like to address some key information regarding this MEDICAL insurance denial that was submitted for DENTAL services.
On 5/10/2021, I signed the data collection form that signified my understanding of the information listed and consented for. On this specific form, it clearly states “As a courtesy our office will file your medical claim to the health insurance plan based on the information you have provided.” You billed my health insurer, Priority Health, that I have an HMO with, included in their TMJD policy that will be covered.
Per that policy, the ICD-10-CM diagnostic codes that Dr. Jerry Mulder put on my summary report are covered under my medical insurance and they are listed below:
-M26.633 Articular disc disorder of bilateral temporomandibular joint
-M26.623 Arthralgia of bilateral temporomandibular joint
-M26.51 Abnormal Jaw Closure
-M26.53 Deviation in opening and closing of the mandible-M26.69 Other Specified disorders of temporomandibular joint (converted from old ICD-9-CM 524.64 Temporomandibular sounds on opening or closing)
-M27.8 Other specified diseases of jaws (concerted from old R68.84 Jaw pain)
-R51.9 Headache, unspecified
-M79.11 Myalgia of mastication muscle
-M79.12 Myalgia of auxiliary muscles, head and neck
-R42 Dizziness and giddiness
-H92.03 Otalgia, bilateral
Not listed in the summary report but a diagnosis that is a pertinent TMJD diagnostic code, M26.60 Temporomandibular joint disorder, unspecified.
On 5/10/2021, I had multiple imagining, testing, and procedures completed. I have listed these below with proper CPT medical codes that are covered by this policy:
-New Patient Consult: 99241
-Cone Beam Computed Tomography (CBCT): 70486
-Myotronic’s K7x Sonography Joint Vibration Analysis (JVA): 77077
-Myotronic’s K7x Electromyography (EMG): 95872
-Myotronic’s K7x Jaw Tracking (CMS): 76377
-Unlisted procedure, craniofacial and maxillofacial: 21299 [to be utilized for orthopedic appliances and not D9940 or D7880]
-Cold Laser Therapy: 97026
I’m determined to get these services covered so I am able to continue my treatment. But to do so, medical services need to be billed correctly. With my extensive medical background and years of medical coding and billing, the services that were agreed upon and provided should be at least 50% covered and not strictly declined due to a claim error that was not done on my behalf. I am going through the appeal process with Priority Health and also with The State of Michigan.
I have faith that you will be able to resubmit to my insurance provider with correct coding, establish the medical necessity of the treatment, and an expedited redetermination can be approved as quickly as possible. My prosthesis have already been completed and I would like to start my treatment before new ones are required.
Please confirm when this request has been submitted and follow up with me regarding updates.
Thank you,
Amy J Johnson BSN, RN, CMA (AAMA)
submitted by /u/FutureCRNA23
[link] [comments]
Hey all, first time post in this group. So far, I was able to find a user that had a similar instance with this and was able to get her insurance to cover it. I have had TMJ issues for nearly 15 years and have never had an issue with my medical insurance covering services for two other TMJ providers and Oral Maxillofacial Surgery/Hospital Dental Clinic at UofM, which all would not touch my jaw or stated that I was not a surgical candidate. This TMJ provider, I felt was my last resort before looking at the Mayo Clinic which is not near me. Now, this TMJ provider was very upfront about insurance most likely not covering a chuck of the services but that I would have to pay up front and then they would bill insurance after. In my first appointment aka Data Collection appointment, I had to pay $695 up front. I then went forth with paying $3000 that day to get the ball rolling on my treatment that is medically necessary and that I needed. With not having any issues in the past with insurance coverage, I didn’t think that it would be flat out denied. So I ended up canceling my follow up appointments to receive my orthopedic appliances due to not having the other portion ($2000) to pay for the remaining bill. When I called to cancel that appointment because I was still waiting to hear back from my insurance company, the “billing” person in this office didn’t sound like they are willing to resubmit my claim to insurance and said that when I was ready to complete the treatment to call them back. Also, googling this office they have a handful of bad reviews specifically due to this same issue but more positive reviews. My denial specifically stated that is was denied for: Dental services such as dental x-rays and dental evaluation/work-up are not covered. After review of the information submitted, the Complex Radiologic Exam (X-Ray), joint imaging, and dental work-up are considered a dental service and are not covered. Therefore, the requested imaging and evaluation are denied. My next step that I did was pulled the Medical Policy for Temporomandibular Joint Disorders, reached out to insurance company inquiring about what ICD-10-CM & CPT codes were used in the claim, requested an appeal with insurance company and requested an external review with The State of Michigan and typed up an email to office to request them to resubmit the claim. That email is below: Hello, The information below is to be utilized to resubmit my insurance claim for my 5/10/2021 data collection appointment for my TMJD that was denied by my insurance. I have attached both the letter of denial and Priority Health’s TMJD policy. I would like to address some key information regarding this MEDICAL insurance denial that was submitted for DENTAL services. On 5/10/2021, I signed the data collection form that signified my understanding of the information listed and consented for. On this specific form, it clearly states “As a courtesy our office will file your medical claim to the health insurance plan based on the information you have provided.” You billed my health insurer, Priority Health, that I have an HMO with, included in their TMJD policy that will be covered. Per that policy, the ICD-10-CM diagnostic codes that Dr. Jerry Mulder put on my summary report are covered under my medical insurance and they are listed below: -M26.633 Articular disc disorder of bilateral temporomandibular joint -M26.623 Arthralgia of bilateral temporomandibular joint -M26.51 Abnormal Jaw Closure -M26.53 Deviation in opening and closing of the mandible-M26.69 Other Specified disorders of temporomandibular joint (converted from old ICD-9-CM 524.64 Temporomandibular sounds on opening or closing) -M27.8 Other specified diseases of jaws (concerted from old R68.84 Jaw pain) -R51.9 Headache, unspecified -M79.11 Myalgia of mastication muscle -M79.12 Myalgia of auxiliary muscles, head and neck -R42 Dizziness and giddiness -H92.03 Otalgia, bilateral Not listed in the summary report but a diagnosis that is a pertinent TMJD diagnostic code, M26.60 Temporomandibular joint disorder, unspecified. On 5/10/2021, I had multiple imagining, testing, and procedures completed. I have listed these below with proper CPT medical codes that are covered by this policy: -New Patient Consult: 99241 -Cone Beam Computed Tomography (CBCT): 70486 -Myotronic’s K7x Sonography Joint Vibration Analysis (JVA): 77077 -Myotronic’s K7x Electromyography (EMG): 95872 -Myotronic’s K7x Jaw Tracking (CMS): 76377 -Unlisted procedure, craniofacial and maxillofacial: 21299 [to be utilized for orthopedic appliances and not D9940 or D7880] -Cold Laser Therapy: 97026 I’m determined to get these services covered so I am able to continue my treatment. But to do so, medical services need to be billed correctly. With my extensive medical background and years of medical coding and billing, the services that were agreed upon and provided should be at least 50% covered and not strictly declined due to a claim error that was not done on my behalf. I am going through the appeal process with Priority Health and also with The State of Michigan. I have faith that you will be able to resubmit to my insurance provider with correct coding, establish the medical necessity of the treatment, and an expedited redetermination can be approved as quickly as possible. My prosthesis have already been completed and I would like to start my treatment before new ones are required. Please confirm when this request has been submitted and follow up with me regarding updates. Thank you,Amy J Johnson BSN, RN, CMA (AAMA)
submitted by /u/FutureCRNA23 [link] [comments]Read Morer/HealthInsurance