Hi, I’m looking for some advice on a stressful issue that’s been going on a while!
Last year, I started having TMJ issues. I got a medical insurance policy that explicitly covered TMJ issues in its policy document.
The first dentist I went to I didn’t like, but that office took CT scans that showed I had damage to the joint. They ultimately billed my insurance successfully for like $1000.
The second dentist was great in terms of treating my TMJ; he made me a hard plastic appliance that sets my jaw in a good position at night. However, up front, this office said they struggle with medical insurance claims and weren’t sure if they would be able to get this covered. I told them my insurance covers it for sure and we’d figure it out.
After I got the guard, I tried to talk to their office about filing with insurance. They wanted to file with dental codes, which, from my research and conversations with my insurance company on the phone, would not be covered. I actually found them a document from a company that helps dentists file medical insurance that lists medical codes to use.
After a few months, they selected one of those codes and filed the insurance. However, the code is the non-TMJ code; it’s for plastic guards that aren’t specifically for TMJ things. My insurance denied the claim on that basis.
I called my insurance company and they told me the office needs to re-file my claim with a better code. They could not tell me which code would be better. I read other medical codes off to them from the billing documents I found myself. They said one code I named was covered… but it doesn’t seem like the greatest code. Of course, I am the patient, not a medical biller, so I don’t know what I’m doing.
Now I need more outside, knowledgeable help. My dentist doesn’t know how to handle this as far as I can tell. I don’t want to pay this in full as it’s almost $1000, and it SHOULD be covered. Here is the language from my insurance policy:
“The following non-surgical treatments meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes in the treatment of TMJ dysfunction:intraoral reversible prosthetic devices/appliances (encompassing fabrication, insertion, and adjustment).”
That is exactly what I got.
Should I find a patient advocate? Should I file an appeal and lay out my situation in a letter that I got an intraoral device and my insurance just needs to cover it by talking to the dentist?
I’ve got until the end of this month to file an appeal with my insurance so I need to figure this out soon. Any advice on how to solve this is greatly appreciated! 🙏
submitted by /u/dothesamba
[link] [comments]
Hi, I’m looking for some advice on a stressful issue that’s been going on a while! Last year, I started having TMJ issues. I got a medical insurance policy that explicitly covered TMJ issues in its policy document. The first dentist I went to I didn’t like, but that office took CT scans that showed I had damage to the joint. They ultimately billed my insurance successfully for like $1000. The second dentist was great in terms of treating my TMJ; he made me a hard plastic appliance that sets my jaw in a good position at night. However, up front, this office said they struggle with medical insurance claims and weren’t sure if they would be able to get this covered. I told them my insurance covers it for sure and we’d figure it out. After I got the guard, I tried to talk to their office about filing with insurance. They wanted to file with dental codes, which, from my research and conversations with my insurance company on the phone, would not be covered. I actually found them a document from a company that helps dentists file medical insurance that lists medical codes to use. After a few months, they selected one of those codes and filed the insurance. However, the code is the non-TMJ code; it’s for plastic guards that aren’t specifically for TMJ things. My insurance denied the claim on that basis. I called my insurance company and they told me the office needs to re-file my claim with a better code. They could not tell me which code would be better. I read other medical codes off to them from the billing documents I found myself. They said one code I named was covered… but it doesn’t seem like the greatest code. Of course, I am the patient, not a medical biller, so I don’t know what I’m doing. Now I need more outside, knowledgeable help. My dentist doesn’t know how to handle this as far as I can tell. I don’t want to pay this in full as it’s almost $1000, and it SHOULD be covered. Here is the language from my insurance policy: “The following non-surgical treatments meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes in the treatment of TMJ dysfunction:intraoral reversible prosthetic devices/appliances (encompassing fabrication, insertion, and adjustment).” That is exactly what I got. Should I find a patient advocate? Should I file an appeal and lay out my situation in a letter that I got an intraoral device and my insurance just needs to cover it by talking to the dentist? I’ve got until the end of this month to file an appeal with my insurance so I need to figure this out soon. Any advice on how to solve this is greatly appreciated! 🙏
submitted by /u/dothesamba [link] [comments]Read Morer/HealthInsurance