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January 13, 2020

Weaving through the Dental/Medical conundrum with Dr. Joan Monaco.

I think most offices expect routine surgical/dental procedures to be covered by a medical carrier, but we are seeing many more insurance carriers request a medical denial before they will process your claim. This can delay reimbursement especially if the patient has dual coverage or multiple plans.

There is a shift in the way medical and dental insurance carriers are viewing a patient’s overall health.  The Centers for Medicaid and Medicare Services, CMS, drives the policy on the reporting standards and requirements for federally backed programs.  They track the data, both financial and clinical and use the information to make better business decisions and policy.  After analyzing data, many insurance carriers have determined that they can save a substantial amount of money by being pro-active in modifying the coverage they offer.  Currently there are many dental procedures that fall under the “medical guidelines” and many medical carriers have a liability to reimburse under the medical plan when specific criteria is met; for example, orofacial medical conditions, many oral surgery procedures, TMD procedures, myofascial pain disorders, trauma and sleep apnea to name a few.

Most dental carriers are aware that coverage may exist under medical and will not issue benefits unless they know that you have exhausted that option.  Obviously, they don’t want to pay for a procedure if the patient is covered under their medical plan.

Lucky for you, NJDA’s Dental Benefits department has been able to assist many of our members with filing the CMS Medical Claim Form and finding appropriate diagnostic (ICD 10), procedural (CPT) and/or HCPCS codes.  To better assist our members, we have offered continuing education programs on this subject and will continue to do so in March and June.

Dr. Joan Monaco will be presenting on the Dental/Medical Integration on the following dates:
  • Thursday, March 19: Wall, NJ | 9AM - 12PM |
  • Wednesday, June 24: Mt. Laurel, NJ | 9AM - 12PM
Click here to register