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Filing Dental vs. Medical Insurance for Your Patients


As an oral surgeon, you perform duties and services that expand the scope of traditional dental care. In fact, may of the procedures that you wind up completing are medical in nature. Thus, it can be confusing for your patients, office staff, or even yourself when it comes to filing insurance claims on the behalf of your patients.

Maximizing Coverage from Dental Plans

Everyone’s plan is different, and because the cost of oral surgery can be a deciding factor for many patients, it’s often recommended that your office provide them with a predetermination prior to treatment. This can determine whether or not any specific types of oral surgery codes are covered, and how much.

Filing Against Medical Insurance

Being able to assist your patients in coverage through their medical plan can make care more accessible. Unfortunately, procedures may sometimes be denied, as they could fall under the description of the dental policy.

Wisdom tooth extractions are often covered by medical insurance - especially if they are unerupted/impacted. If they are erupted however, this may not be the case. The key may be to show that the procedure is medically necessary - such as in the instance of significant infections that compromise the health of the patient, or an emergency such as a fractured jaw.

If the procedure has to be completed within a hospital setting, an ambulatory center, or with the use of anesthesia, filing medical claims may be the only way for the patient to receive any type of reimbursement for the procedure. Depending on the codes being used, it could be that you may need to claim with both medical and dental insurance companies.

Differences in Filing Claims

Because medical and dental claims are filed via two separate forms or systems. It usually takes a small learning curve to become familiar with the claims filing process. Dental codes often have an ICD-9/10 medical code that they convert to, if filing medical claims are an option. Modifier codes may also be used. The ICD coding handbook is very extensive, but the codes related to dental-oriented procedures are fairly straightforward and easy to identify. If a parallel code cannot be identified, then chances are that the procedure cannot be cross coded from dental into medical.

Medical claims cannot be filed on a dental claim form, or vice versa. Inaccurate coding and form use is one of the biggest mistakes made by oral surgeon offices when filing for patient benefits. All medical claims must be made using the CMS-1500 form; otherwise they will be rejected. Fortunately, some practice management software allows cross coding to be done electronically.

Is it Medically Necessary?

The other mistake that oral surgeons make is not cross coding the procedure as if it were medically necessary. Medical insurance will typically cover conditions related to infections, pathology, trauma, TMJD, and sleep apnea. Including the diagnostic tests, exams, and treatment for those conditions – as long as they are medically necessary. Documentation is vital.

Having a Financial Policy in Place

As with any insurance claim, there is always a risk of it being denied for reimbursement by the carrier. Thus, it is vital to have a concrete financial policy in effect, along with financing options made available, in the chance that your patient cannot access coverage, yet still requires treatment.

Business - Medical and Dental Industry

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This article contains general information only. Sunflower Bank is not, by means of this article, rendering accounting, financial, investment, legal, tax, or other professional advice or services. This article is not a substitute for such professional advice or services, before making any decisions related to these matters, you should consult a qualified professional advisor.