Posted by Perhaps you’ve exceeded your dental insurance annual maximum, but you still have some dental procedures to cover. Now you’re worried and asking “Does medical insurance cover dental surgery?”. Well, statistics show that there are at least 60% of people who don’t know if their medical insurance covers dental surgery like you. This article is for you all!
Medical insurance can cover your dental surgery bills, but it depends on several factors like; medical necessity and type of condition, etc. All of these and more are covered for you in this article.
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Table of Contents
Does Medical Insurance Cover Dental Surgery?
Yes, medical insurance covers dental surgery, but coverage depends on the type of condition and the medical necessity of the treatment. Major dental surgeries often require you to use medical insurance, because dental insurance does not provide the adequate coverage needed for such procedures.
But for your medical insurance to guarantee coverage for your dental procedure, you will have to prove that it directly affects your health. Clear enough?
Medical Versus Dental Coverage For Dental Surgery
If you have to consider medical insurance over dental insurance for your dental surgery, then it is important you know why.
Most dental insurance plans follow the 100/80/50 rule. This means that preventive treatments get a hundred percent coverage, eighty percent coverage is for basic treatments that do not require extensive surgeries and major surgeries only get fifty percent coverage (some don’t even get at all).
Medical insurance often comes in when one needs to foot the bill for the remaining fifty percent of coverage from the dental insurance company or even the entire dental procedure bill.
Are you also wondering If Oral Surgery is covered by dental or medical insurance? See that amazing work ours.
Sometimes, it could be that you have exceeded your dental insurance plan annual maximum (this is usually worrisome). Medical insurance can also help cover additional bills as long as you can prove that it affects your general well-being.
Requirements For Medical Insurance To Cover Dental Surgery
For a dental procedure to be approved and covered by medical insurance, it must:
- Treat A Medical Condition
- Be Medically Necessary, and
- Have a Corresponding Medical Code
1. Treat A Medical Condition:
If a condition is purely dental, forget it! Whatever condition you want your medical insurance to cover must be medical. This means that the condition affects other areas of your health beyond your mouth region.
You can get more luck if the treatment of your current medical condition can somehow prevent another medical condition in the future, that your medical insurance company will have to take sole responsibility for.
2. Be Medically Necessary:
Your procedure could be treating a medical condition, but it must also be “medically necessary”. The National Association of Insurance Commissioners (NAIC) defines this as “a diagnosis, treatment, cure or relief of a health condition, illness, injury or disease”. It can only be for the sake of treating a condition.
3. Have a Corresponding Medical Code:
Insurance claims basically work with codes and different codes apply to different insurance terms such as:
- The difficulty of the procedure.
- Use of anesthesia or sedation
- Specific tooth (teeth) to be treated
Ensure you have a knowledgeable provider who can use the proper codes to make your claims.
Medical Insurance Deductibles And Copays For Dental Surgery
Medical insurance coverage for dental surgery is not the same as coverage for other surgeries. Therefore the cost of deductibles and copays are not quite the same.
The cost of deductibles for dental surgery is a little high when you’re using medical insurance. This means that the initial payment you make before insurance kicks in for your procedure will be a little more than the regular price you know.
The same applies to your copays, which cover a little part of the cost for every visit to your dentist. It is important to keep it in mind and be prepared.
15 Dental Procedures That Are Covered By Medical Insurance
Below are dental procedures that are covered by medical insurance:
- Oral infections, cysts, and oral inflammation.
- TMJ appliances and headache treatment
- Sleep apnea appliances.
- Mucositis and stomatitis(from chemotherapy and other treatments).
- Accidents to teeth.
- Dental implants and bone grafts.
- Wisdom teeth extraction.
- Biopsies.
- Facial pain treatment.
- Botox injection for bruxism.
- Dental clearance exams before chemotherapy.
- Congenital defects.
- Emergency trauma procedures.
- Exams for oro-facial medical problems.
- CTBT and Tomography.
15 Dental Procedures That Are Not Covered By Medical Insurance
The following are dental procedures that are not covered by medical insurance:
- Teeth whitening.
- Dental veneers.
- Cosmetic bonding.
- Orthodontics (Braces).
- Dental crowns.
- Dental bridges.
- Dental fillings.
- Dental sealants.
- Periodontal therapy.
- Dental cleanings.
- Dental exams.
- Fluoride treatments.
- Root canal therapy.
- Night guards.
- Retainers
See this to know if dental insurance covers retainers.
How To Properly File A Medical Insurance Claim For Your Dental Surgery
A properly filed claim is a key factor in having medical insurance cover your dental surgery. Oftentimes, people file the wrong claims or make other sorts of mistakes in their claim forms that result in claim denial.
Here’s how you can properly file a claim for medical insurance for your dental surgery:
- Fill Your Claim Form Correctly
- Get All The Documents/Information You Need, and
- Submit Your Claim
1. Fill Your Claim Form Correctly:
The thing about filing a claim for medical insurance to cover dental surgery is that dental and medical codes are different. But you will have to accurately cross-code to get the claim you need.
If there is no way to cross-code, the CDT should be given for full transparency and consideration. Also, submit using CMS 1500. A good thing you can do is enlist the help of someone who has adequate expertise in this area. This could save you a lot of stress later.
2. Get All The Documents/Information You Need:
Find out all the documents or information required of you and submit it. Sometimes additional information that further proves your treatment as medically necessary should be added, been when there is no official request made.
3. Submit Your Claim:
Every insurance company has its own claim submission terms and method of submission. If you have fulfilled all the terms stated, submit it at the appropriate time so your file can receive due consideration.
How To Stand A Better Chance of Getting Medical Coverage For Your Dental Surgery
These steps will give you a better chance of getting medical coverage for your dental surgery:
-
Ensure Your Procedure Is Medically Necessary:
Approval of your dental surgery claims largely hinges on the type of procedure you’re applying for. Dental surgery will only be covered by medical insurance if it is “medically necessary”. An example would be surgery to fix a broken tooth that’s causing pain.
-
Get A Referral From Your Dentist:
A referral helps build up your case before your insurance company. Try to include one written by your dentist in your claim documents. Make sure that the necessity of your treatment is stressed in the referral.
-
Get Pre-authorization For Your Procedure:
Get pre-authorization from your insurance company and try to do it early enough, before your procedure. This will give them enough time to review your claim, and you will have enough time to appeal if your claim is denied.
-
Consider Second Opinions:
If your claim is rejected you might need to get a second opinion to help your appeal. Even if that is not the case, second opinions never hurt when you’re trying to get a claim approved.
-
Use An In-Network Provider:
This drastically reduces cost. Using a provider that is within a network that is in partnership with your insurance company helps you stand a high chance of getting coverage.
Coordination of Benefits: When Dental Meets Medical Insurance
Did you know that you can combine your dental and medical insurance to cover one dental procedure? Exciting, right?
In insurance, this is called “Coordination of Benefits“. It is actually one of the best ways to enjoy what both coverage has to offer. But this usually comes with some conditions.
To successfully combine both insurance plans, both companies must be aware that they are providing coverage. Usually, medical insurance takes up the bill from dental insurance stops.
Although the chief aim of “coordination of benefits” is to ensure you do not get reimbursed twice, it can also work to your advantage by providing you with complete coverage.
Frequently Asked Questions
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Conclusion
We believe you read this article and now you know that you can always get the help you need for your dental surgery through medical insurance. Ensure that you have fulfilled the necessary conditions that you’ve read in this article before you submit a claim. If your claim is denied, don’t lose hope, try appealing. We’re rooting for you.
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