Introduction To Insurance Information
Here at CPC we care that our patients are able to understand and receive the best possible reimbursement from their insurance. We have provided this insurance section with many links to provide each patient with the skills necessary to submit to their insurance properly and to understand why we are not able to submit for them. We hope this information is helpful, easy to follow, and clear to use. We also wish you the best of luck in submitting your insurance claims.

Sincerely,

Sue Pierce
Insurance Specialist

Insurance Links
     Frequently Asked Questions
     Glossary of Insurance Terms
     Before Coming In
    Payment Options and Billing
    Submitting Claims
    Prior Authorizations
    Individual Insurances
    TAP Packet and Instructions

Frequently Asked Questions
For the treatment of Sleep Apnea

Q. Do you accept my insurance?
A. Because Dr. Spencer is in the unique position of being a dentist (DMD) treating Sleep Apnea, which is considered a medical condition, he is unable to contract with insurance companies for payment. He is therefore unable to accept insurance as they will not pay for many of the treatments we offer. We do help our patients to submit to their insurance and find that they are able to receive better coverage when they submit individually.

Q. Will my insurance pay for this? Do I have benefits for Sleep Apnea treatment?
A. Each insurance policy is different. Many individual policies do have benefits regarding the treatment of Sleep Apnea. Because this is an alternative treatment to CPAP for most of our patients, we have found that most policies will pay for our treatment here at the same percentage rate that they paid for the CPAP trials. If your policy has an exclusion for the services provided here in our office, your insurance company will not cover your treatment. We suggest that you call your insurance or look through your benefits booklet to find out what they might cover.
Some questions to ask them or look for:
Ask if your insurance has coverage for an oral appliance towards the treatment of Sleep Apnea.
Find out if there are any prior authorizations needed before you come in for treatment, or for any procedures here in our office. (If there are prior authorizations needed see section under Prior Authorizations). Prior authorizations must be completed before your appointment with us.
Let them know that Dr. Spencer is who you will be seeing for this treatment and that he is not an in-network provider. Also let them know that you were referred to our office and would like to find out what steps are needed for your insurance to reimburse at the in-network rate. (See Prior Authorizations and Before Coming In links for further help).
Also find out the amount of deductible you have left to pay and what procedures and office visits would be covered when speaking with your insurance.

There are also some items that insurances require to cover the treatment with us. It is usually required for the patient to have an in-network doctor refer the patient to us. It is also good have a diagnosis of Sleep Apnea which comes from a sleep study (see Glossary and Before Coming In for Treatment links).

Q. Do you submit my claims for insurance?
A. We ask that our patients submit their own claims as we are not able to submit claims to your insurance company. We help our patients with the submission process by providing the patient with claim forms to submit to their insurance. If your individual policy has benefits for this treatment they will reimburse you, the patient directly.

We are contracted with Medicare, which enables us to submit all Medicare claims. (See Medicare under the Individual Insurances link).

Q. Is Dr. Spencer a preferred provider for my insurance?
A. Because Dr. Spencer is a dentist he is usually not able to contract with insurance for the treatment of Sleep Apnea, which is considered as medical condition, not dental.

The only insurance that we have a contract with is Medicare. Medicare patients will only pay the co-pay at each office visit, but may be responsible for payment in the case that Medicare doesn’t completely cover the procedure. (See Medicare under the Individual Insurances link).

Q. If Dr. Spencer is not a contracted provider, can I see him?
A. Some policies require you to initially use their “contracted or preferred providers”. However, it is possible to see someone outside of the network. Some insurances have an out-of-network rate which requires additional information to be submitted for this allowance. Check with your insurance carrier to see what their rules are.

Sometimes it is only necessary to have a referral from an in-network provider to see the doctor here, and then insurance will pay partially. If needed, it may be possible to receive an authorization for an out-of-network waiver from our office. You may also explain to your insurance that we are the only doctor in the area that works specifically with oral appliances for the treatment of Sleep Apnea. There are no other contracted doctors in the area that are in the network that offer these services. Because of these circumstances, often the patient is able to receive reimbursement even though we are not in the network.

Q. Why do you ask for my insurance card and information if this office doesn’t submit?
A. We ask for a copy of your insurance card at check in and will input your insurance information into our system so that we can help you later with this complicated insurance process. Many times after the patient submits a claim, the insurance will ask for additional clinical notes and have questions for us. Some sleep appliances will also require prior authorization before receiving the appliance. We use your insurance card for reference and to help quicken the process. Without this info we would not be able to submit the additional notes and diagnosis info when requested.

Q. Does insurance consider this treatment as medical or dental?
A. The treatment for Sleep Apnea usually has better coverage when submitted as a medical procedure rather than a dental procedure. Even though the doctor is a dentist (DMD), the actual treatment is linked to a medical diagnosis and your medical insurance will be the only one to cover these services.

When we print out claims for you at the end of your office visit we will always print them with medical codes for you to submit. If you find that you medical insurance doesn’t cover any of the treatment, we can try to submit the imagery (Panoramic x-ray, CT scan) to your dental insurance. You will just need to let the front receptionist know to change the codes.

Q. Can these procedures be billed to my dental insurance?
A. Benefits for Sleep Apnea are usually through the medical portion of your policy. We find more and more frequently that our patients are able to be reimbursed for their treatment with us through the medical. Sleep Apnea is not usually covered under dental.

Q. How do I submit claims to my insurance?
A. This will be fully described under the Submitting Claims link.

Q. What if I have problems with submitting my claims?
A. We are happy to help you with any problems you might have. We will provide you with any documentation or letters to help with your reimbursement. Please let us know if you are difficulty submitting your claims so that we can assist you. (See section under Submitting Claims link).

Q. What all do I need to come in for an initial evaluation?
A. To set up an initial appointment you will need to call our office and reserve a time. It is very important for insurance purposes to have a doctor referral to come see us. Most insurance companies like to see that the patient has been referred by a regular dentist or physician. Some insurance companies require pre-authorizations for some procedures. (For more additional info on pre-authorizations see Before Coming In and Prior Authorization links).

We will provide paperwork to fill out right as you come in for your first appointment. The doctor will need to have a panoramic x-ray for his first evaluation. Many dentists will take a panoramic x-ray every couple of years. We are able to use these (or a copy) if it was taken in the last 6 months. We like to have it current as your mouth is constantly changing. We can also take one here at your first appointment if you don’t already have one.

Q. How is Sleep Apnea treated? What is typical treatment for Sleep Apnea?
A. At our office we offer conservative treatment by using oral appliances that fit into the mouth to correct the airway at night. The appliances (or splint) usually consist of two retainers, an upper and lower, that fit over the teeth. The two retainers are linked together which holds the jaw in place and moves it into the correct position. The reason that most people only have a problem with breathing at night is that the jaw naturally holds itself forward during the day and will relax and fall back at night. This causes the blockage during the night. The splints are designed to hold the jaw forward to the natural daytime position while sleeping. This helps most patients to breathe well the entire night without waking up.

At the initial exam, the patient will go through a screening process. We will find out if they are a good candidate for the appliance. They will have a visit with the doctor’s associate and a panoramic x-ray will also be taken to determine whether or not the patient’s symptoms will be solved with using the splint. After the first visit with the doctor, the patient will usually be scheduled for a second visit to be fit with the appliance. In most cases the doctor will need to review some other imagery (CT scan of the airway, MRI) before the patient receives the splint. Most of our patients will be fit with the appliance at the second visit and return in two weeks for their first follow-up. These follow-up appointments (or adjustments) allow for adjustment to the splint which will slowly move the jaw to the maximum opening for breathing.

Depending on the symptoms and severity, our patients are fit with a variety of different splints to correct the problem. All treatments follow this same guideline. Most of our patients return for 3 to 4 follow-ups before the appliance has been adjusted to its correct position.

Q. Will my insurance cover oral appliance therapy for treatment of my obstructive sleep apnea?
A. The good news is if your insurance company covered your CPAP treatment or palatal surgery, they will most likely cover oral appliance therapy. If you were referred to our office without first trying CPAP, then there are certain parameters that your insurance company will define, based on the severity of your sleep apnea. These are usually based on “AHI” or the Apnea Hypopnea Index. If your AHI is below 15, then some insurance companies will require a letter from your family doctor or sleep specialist stating why it is medically necessary for you to be treated—such as excessive daytime sleepiness, high blood pressure, depression, etc. In most cases oral appliance therapy will be covered in these situations. If your insurance company covered your CPAP treatment, but they deny coverage of oral appliance therapy, please let us know so that we can help you get the coverage that you deserve.

Glossary of Insurance Terms

Allowable charge: the amount that network doctors and other health-care providers contracted by your health plan have agreed to accept as full payment for covered health-care services and supplies.

Benefit: The portion of the cost for covered health-care services and supplies that your health plan is responsible for paying.

Claim: The paperwork that is submitted to the insurance company to be paid. We print out a claim form for the patient to submit at the end of their appointment when they are submitting to their insurance. This can be filled out and mailed to the insurance company and will be considered a claim. It is usually only one page in length.

COB: Coordination of Benefits. This is the technical name given when a patient has more than one insurance and the insurance company is willing to move the claim on to the next insurance to be processed. This usually happens when a patient has a primary insurance along with a secondary. The primary insurance will automatically process the claim and then move the claim forward on to the secondary insurance.

Coverage: The range of health-care services and supplies for which your health plan provides benefits.

Covered Benefits: This refers to the benefits that are covered by your individual insurance plan. Each insurance plan is different and every insurance company decides differently how they will cover procedures. If your policy states that it is a covered benefit, then they will pay a percentage of the entire cost. The percentage covered will be determined directly by your policy. If it is not a covered benefit, your insurance will pay no portion of it.

CPT code: Current Procedural Therapy code. This is the national medical coding used by all medical insurances to identify the procedures done in our office. This is also how insurances identify the amount they will reimburse for that charge or service. At our office, we use CPT codes rather than dental codes. We find that the medical portion of most insurances cover more for TMJ than dental coding does.

Dental Code: Dental codes will always begin with a “D” and have 4 numbers following. Some dental codes will have zeros at the beginning instead of a “D”. This is also acceptable. Dental coding is used nationally by all dentists to identify the charge or service that was provided.

D.M.D.: Doctor of Medical Dentistry. These credentials represent dentistry and are similar to DDS, (Doctor of Dentist Science) the credentials of most dentists. A DMD doctor will have more training in the medical field. This gives Dr. Spencer a greater background for treating TMJ and Sleep Apnea, both of which are considered medical conditions.

DOS: Date of Service. This is the actual date that the patient was in seen in the provider office for treatment. The Date of Service is important when asking insurance questions, as they will only have information on the dates that have been submitted and received by their office. If they don’t have the information, then it is possible that the claim was lost or needs to be submitted a second time.

Durable Medical Equipment (DME): This is the technical name for the appliances that we use here in our office. Durable medical equipment (DME) is equipment that is primarily and customarily used to serve a medical purpose, can withstand repeated use, and is appropriate for use in the home. Some examples of DME include hospital beds, walkers, wheel chairs and oxygen tents. Some insurances require a preauthorization be made before any Durable Medical Equipment is issued to you. Usually this preauthorization is needed only when it is $300 or more in price. All of our appliances fit this criteria. Preauthorization will usually require a description of the device, what it is to be used for along with diagnosis codes and other CPT codes.

DX code: Diagnosis code. This represents the coding used for each diagnosis that the doctor has prescribed for the patient. The diagnosis is important for reimbursement from insurance and is always important to include when filling out. It is usually the same as the ICD-9 code.

E.O.B.: Explanation of Benefits. Letter or statement that the insurance will send to the provider and to the patient regarding any claims that the insurance has received and processed. The purpose of the EOB is to show an itemized statement of each charge and the portion of that charge that was paid. The EOB will also have a reason for payment of each charge. Insurance sends this statement for the patient to see what has been paid or what the insurance has received. If there is no EOB sent to the patient, then it is likely that the insurance never received the claims. If DOS are missing on the EOB, then it is likely that the insurance didn’t receive claims yet or are still processing them.

Exclusion: A name for the benefits that are not covered in your individual policy. When your individual policy doesn’t cover certain procedures or certain treatments, it is excluded from that policy and will not be covered. There is usually no way to avoid an exclusion in your policy, as that specific policy does not pay for those treatments and procedures.

ICD-9 code: The International Classification of Diseases, Ninth Revision. These are the codes used to classify and index all medical diagnoses. This is the national standard coding that all insurances and billing will understand and be able to work with. If ever asked for your diagnosis, there is a number and name for each code.

In-Network Provider: Most doctors will contract with different insurances to become an in-network provider. The insurance will contract with the doctor to pay a certain price for certain procedures. Because the insurance and the doctors have this contract the insurance will usually pay at a better rate when the patient is seen by in-network providers. If the doctor is not an in-network provider, then the insurance may choose to pay at a later rate or not at all. Dr. Spencer is only contracted with Medicare to be an in-network provider.

Letter of Medical Necessity: A letter written by the provider (doctor office) to the insurance to explain the medically necessary reasons for the procedures performed or to be performed. This letter can be requested from the patient or the insurance and only is written after we have seen you as a patient. This letter specifies the diagnosis and the reasons why the doctor feels that these procedures are necessary for the patient. We can write a Letter of Explanation if the patient has not yet been seen in our office.

Network: A group of doctors, hospitals and other health-care providers that have been contracted by your health plan to provide health-care services and supplies at agreed upon amounts called “allowable charges.”

Out-of-Network Provider: Some insurances require that patients are only seen by doctors that have contracted with the insurance for a specific rate. If the patient is seen by a doctor that is not in this contract, it is considered an out-of-network provider. In this case the insurance will not pay or reimburse at the best negotiated rate. They will usually pay at a lower rate or not at all, which forces the patient to pay for the entirety of the office visits.

Out-Of-Network Waiver: This is a letter that is written by the provider’s officer to the individual insurance upon request. It is written when the insurance or patient requests a letter to provide a written explanation why the doctor is not a provider for the insurance. The letter explains that there are no other doctors in the area that provide this service. Our patients have no other doctors to choose from for these treatments. The letter will also request that the insurance consider the doctor at an in-network rate, rather than the out-of-network rate that will reimburse less. If your insurance requests that an out-of-network letter be provided then we are happy to write the letter. When the insurance receives an out-of-network waiver it is very possible that they will consider these fees at the in-network rate.

Out-of-pocket expenses: Costs that are paid by you, the patient, not your health plan. Such as the following:

Copayment (copay): A set fee your health plan may require you to pay your doctor or other health-care provider at each visit for certain covered services.

Deductible: A fixed amount your health plan may require you to pay for certain covered services and supplies each year before your health plan starts paying specified benefits. Copays are not credited toward your deductible. Most office visits will have a co-pay of $20 or $40, and the patient will be billed the remaining amount of the office visits until their deductible is met. The deductible will need to be met (paid for) before the patient can be reimbursed by their insurance for all office visits with any doctor.

Predetermination: When insurance requires information and an approval code before treatment is begun. Some insurances require a predetermination (preauthorization) for visits with us. This must be completed before the actual appointment. The patient may call their insurance to see if their insurance needs any information to be processed before they come in for treatment. For predetermination most insurances will need a referral from your regular doctor, a description of what you are being seen for and the reason for treatment with us. If the insurance needs information for the services that we will provide, we are happy to give these.

Provider: A doctor, hospital, or other medically licensed or medically certified person or facility that provides health-care services or supplies.

Sleep Study: This is a study that is usually ordered by a sleep doctor when a patient shows signs of sleep apnea or other related symptoms. The sleep study is usually performed at a sleep lab or at the hospital. A sleep study should also be taken before a patient is seen by our office. Dr. Spencer and his associates will request a sleep study before the patient will come in for their first visit. A review of this report is required by our office before being treated for sleep apnea as a new patient.

Tap Packet: This is a packet we have specifically designed for our sleep patients who are receiving a TAP appliance. Most of our patients will need to send the TAP packet right after their first office appointment. They will include it with their first claim, and a copy of their Sleep Study for predetermination before they return to receive the actual appliance. Our office will let the patient know to download and send it with your sleep study for insurance reimbursement. Most insurances require this information after your first visit with us as the patient prepares to receive the actual splint. It is about 15 pages long and the entire packet should be included. It is a full explanation for the use of the TAP appliance (or any oral appliance) for sleep apnea and gives professional consideration on its usage for healing medicinal and curative power for your individual insurance. This will help to give our patients better reimbursement.

TMD: Temporomandibular Joint Dysfunction. This is the dysfunction of the jaw joint and the technical name for the diagnosis of jaw joint problems. (TMJ and TMD may be used interchangeably). When being treated in our office for jaw problems TMD or TMJ are the diagnoses most associated with all jaw pain and dysfunction.

TMJ: Temporomandibular Joint. This is the jaw joint right below the ear that is usually the cause of facial pain, headaches and jaw pain related symptoms. Dr. Spencer’s Office focuses on the therapeutic remedies to heal TMJ and TMD.

Before Coming In For Treatment
And Prior Authorization
(Review all of this before calling your insurance)

Here is a helpful guide for steps that should be taken before coming in for your first office visit with us. When you call our office to schedule, we try to review all of these steps with our patients. We find that it is efficient to give our patients this information in a written form so that they can be prepared before we ever speak with them. This process can be quite complicated and confusing. We find that following these steps will speed up the process and eliminate extra time and phone calls.

Important Information:

All patients that come in to our office for appointments will pay out of pocket for the services rendered. It is a requirement because we are never certain if insurance will pay for any of the services that we render here in our office. We will always let our patients know all of the fees and possible charges prior to their visit so that they are aware and prepared for all costs. (Medicare patients are an exception to this as we are a contracted provider with Medicare and they only need to pay the office co-pay. See the Medicare section under the Individual Insurance link.)

Our patients must pay at the time of service due to the fact that we are unable to contract with your insurance to be providers. Dr. Spencer is a dentist (DMD) treating Sleep Apnea, which is not considered a dental condition, but instead is considered a medical condition. For this reason he is unable to contract with the medical portion of our patients’ insurance. We will not be a listed provider for your insurance and are considered an out-of-network provider (unless it is Medicare). This also means that it is not possible for us to submit to the insurance for you. Therefore, we help our patients to submit to their insurance and their reimbursement, if any, will be sent directly to the patient. We will print out a form at the end of the appointment for our patients to use for submitting to their insurance. This form will have medical coding. We find that most of the procedures in our office will be covered more entirely by the medical portion of insurance. If our patients find that their dental insurance will cover portions of this treatment, then we will be happy to change the coding.

If you have any questions on any of this information, or on how to submit your claims, please see our Submitting Claims link, and feel free to call our office.

Before Coming In
To Do List:

1. Referral: Get a referral from your doctor’s office if they didn’t already give you one. Bring that referral with you, or have them fax it over to our office. Even if the doctor simply says that it is ok to come here, that will be enough for the insurance. It is mandatory to have a referral before coming to see us. The insurance will be more willing to reimburse if we have sufficient proof to show these symptoms.

2. Panoramic x-ray: Have your dentist make a copy of your panoramic x-ray if you have a current one. (Current is within the last six months. If it is older, the mouth may have changed significantly and we will need to take a new one). You may simply bring it with you or have it mailed to us. We are also able to call your dentist and find out if you have a current pano. We can take the panoramic x-ray here, on your initial visit if you do not have a current one.

3. Sleep Study: Our office will need a copy of your first Sleep Study. We can call to get a copy of your Sleep Study if you don’t already have it with you. We will only need the location where it was taken or a doctor’s office that has a copy. If you have not yet had a Sleep Study taken, call our office and let us know.

4. Insurance Information: Call your insurance or search through your benefits booklet to see if your insurance will cover your office visit with us. Here are some suggestions of questions to ask your insurance:

Ask if your policy covers the treatment for Sleep Apnea. Let them know that you have been referred to our office for conservative treatment, using oral appliances, for sleep apnea. This is an alternative to C-PAP. Ask what will be covered as you come in for your first visit.
Ask if there are any prior authorizations that will need to take place before coming in and what you will need to do. Most insurances do not need prior authorization before your first appointment. (If there are authorizations that need to be done see Prior Authorizations below). If prior authorizations are needed for the appliance or for other office visits, those should wait until after the first appointment.
Find out the amount of deductible you have left to pay, if you would like to know.
Find out which procedures and office visits would be covered and at what rate (see list of procedure codes below).

It is also important to explain to your insurance why you have chosen to come and see us. Let them know that Dr. Spencer is the only dentist that works in this specific field of interest and that there are no other dentists in the area (all the way to Portland, Oregon) with this expertise. Explain to them that you would like to be considered at an in-network rate for this reason. This can be a very strong point for your case when your insurance is questioning whether or not they will reimburse you.

5. Call our office to schedule an appointment. Your appointment will actually need to be held with a credit card. We do this to ensure that we won’t have our patients fall out on the day of their appointment. We will not charge the credit card unless the patient fails to show up at their appointment or they cancel/reschedule within 24 hours of the appointment.

Prior Authorizations

Some insurances will require prior approval with them before the patient comes in to our office for treatment. And some patients will want to have an estimate for the amount of out-of-pocket expense they will have. Each insurance and each policy is different. We will try to make this helpful, but it can be confusing since each individual insurance will have their own criteria to meet.

Insurances that commonly require prior authorizations before coming in.

Tricare/Triwest
TrueBlue

Insurances that commonly require prior authorizations for imagery (Panoramic x-ray, CT scan or MRI).

Blue Cross of Idaho
Tricare/Triwest
TrueBlue

Insurances that commonly require prior authorization for appliances (DME, TAP, snore guard, all appliances).

Tricare/Triwest
TrueBlue
Blue Cross of Idaho

(For more detailed information on your individual insurance see the Individual Insurances link).

You may give your insurance these following procedure codes and fees for them to process if needed. This will help if they are not sure that your policy will cover the treatment. Remember that even if the insurance says it will pay for treatment, this is not a guarantee. Nothing we do here in our office guarantees payment from the insurance. These are the most common procedures that will take place in our office for our patients’ first two initial visits. This is the typical course of treatment, but there many other varieties as symptoms are always individual. (See Glossary link for word definitions).

List of Possible Procedure Codes and our office visit charges:

First Appointment:

99242 $120.00 Initial examination and Consultation
70355 $79.00 Panoramic X-ray (only when needed)

First or Second Appointment:

70486 $570.00 CT scan (only if indicated. This is the price at our
office only).*
21076 $25.00 Study Models/Impressions (when further treatment
is indicated).

Second Appointment:

E0486 $1800.00 Custom Fit Sleep Appliance. Also called DME***
This is the actual code for the sleep appliance.

*Some insurances will require that the CT scan be taken at an in-network provider office. We can easily refer you to the right office. The price will vary at each office. Some patients will be referred for an MRI. This will take place at another office.

***This is the code for the Sleep Appliance. Most insurances refer to this as Durable Medical Equipment (DME). Many insurances will require a prior authorization be done for any DME over the price of $300.00.

When a Prior Authorization is needed:

Ask your insurance everything that is required to initiate the prior authorization.
Ask what you will need to submit to them.
Ask specific details if you are not for sure what they require.
Ask for the specific fax number, the mailing address, a contact name, their direct phone number and extension, how long the processing time is, what department to Attn it to and a reference number (they might not have one assigned yet).
Mail/fax everything that your insurance has requested. Make sure that you have the correct address and contact information.

Things commonly requested:

         • Referral, reason you are coming to us
         • Clinical/chart notes, office records--ask us
         • Sleep Study--use the first study ever taken, we can make a copy for you
         • Information on the Appliance--We will give this info to our patients at the first appointment usually in the form of the TAP Packet. See TAP packet link if you need to download and print
         • Letter of Medical Necessity, Letter of Explanation--we will provide these for you upon your request
         • Out of Network Waiver--Letter written by our office only upon request if the insurance will accept it. Some insurance companies will only pay at the out-of-Network rate until we provide you a letter stating that our office is the only one in this area that provides this service.

After everything is mailed or faxed, you will want to follow-up on your pre-authorization. If it is faxed, give them a day or two. If it is mailed, give them a week or more. If they didn’t receive it, then verify all of the contact information and send again. Once they receive everything, they should give you a reference number and send it to be processed. Some times they will need additional information from us. They should send us a records request. This will move the process on quickly. Have them give you a time frame for when you will receive an answer.

Any questions or concerns, please call us!!!

Payment Options and Billing

Payment Options

Cash or Check
Credit Card: Visa, Mastercard or Discover.
CareCredit Line, visit www.carecredit.com. Carecredit offers no interest and extended payments plans (everything is determined by your online application). They also offer multiple Interest-Free terms and no interest charges if paid within the specific time period. Apply online before coming in and everything will already be in order for your appointment. You will receive an application approval number, which you will need to bring with you to pay for the appointment.
If these payment options don’t work for you, please speak with our New Patient Coordinator at our office. She will be able to assist you if there are other options available.

Billing in our Office

Sleep Apnea
If you are a Sleep Apnea patient, you will be billed for the appliance at the time of the fitting. The fee that you are charged is your case fee and covers the appliance and all office visits for 1 year. The case fee that you pay is for the appliance only. After you submit your claim for the appliance, your account balance will be at $0 and you will have no more claims to submit for your year.

If further treatment is indicated after one year we will discuss the options available at that time. Each patient case is different. We find that the majority of our patients will only need a year for the follow up visits after they receive their splints. We also find that in complicated cases that more treatment will be necessary than just one year. We usually set up a pay-per-visit after the first initial year is finished. We do this to ensure that the patient knows what the expectations are and will be able to successfully complete treatment.

Submitting Claims for Sleep Apnea

How to fill out and submit your claim

(If you need to authorize visits prior to your appointment please check Prior Authorization or Individual Insurance sections).

We ask that our patients submit their own insurance claims. As you come in for your appointment, when full payment is received, we will provide you with insurance claims to submit to your insurance company for reimbursement. We should print a new form for each office visit. We print these forms for you at the end of the appointment when checking out. If we fail to do so, please ask for a copy of one.

The insurance claim is one page. We find that most health insurance plans (medical insurances) have better coverage for the services that we render in our office than dental plans. Almost all dental plans will have no coverage for Sleep Apnea. The only exception is imagery. Most imagery can be covered by the dental portion of insurance if the medical won’t cover it. We always print all of the claims with medical coding. If you find that you need to submit to your dental, we will need to change the codes. Let the front desk know that you are submitting to dental rather than medical.

You will need to fill out the top and bottom portion of the claim before sending it in. This includes:

Your referring Provider’s name. (This is the doctor of dentist that referred you to OUR office. This is located in the top left of the form, directly under your name and address).
Your signature.
Date (that you are signing the claim, NOT the date of service).
Your date of birth.
Your Policy # (this can also be referred to as the ID or Member number. It can be a combination of letters and numbers and anywhere from 6-15 characters in length)

First Claim Submission

With your first claim it is vital to send some additional explanatory information with it. We will also try to remind you at your initial visit of this extra information.

TAP Packet: This packet consists of professional explanations for the medical necessity of the TAP appliance and other oral appliances that we use for the treatment of Sleep Apnea. We have provided this entire packet online (TAP Packet link, about 15 pages long) and it is also available at our office.
Sleep Study: You will want to attach a copy of your first Sleep Study to this claim submission as well. The first Sleep Study is the most accurate one. It focuses in on the original problem and gives the initial diagnosis without any interference of treatments that have been performed since it was done. We usually can provide our patients with a copy at their office visit, or one may call the place where it was taken to have it mailed to them.

Once you have completed all of the information on the claim, you will need to mail it directly to your insurance company. The claims address is usually located on the back of your insurance card. If it is not on the back of your card, you can either call your insurance company and ask for the address or go to their website to locate it.

If you are from out of state or have insurance from another state it is important to always send your claim to the local area plan (Boise, ID). Even if the address on the card is Louisiana, Montana or Kentucky and it says to send your claims to that address, they will send it back to you requiring you to resend it to the local area plan. This is due to the patient being treated in Boise, ID and insurance will need to process parts of the claim in Idaho first, due to state law requirements, and they will send it along to the other state for you. (Out of state claims will take longer to process for this reason).

After you have sent your claim in, you should hear back from your insurance in about a month. If you do not receive anything back in the mail or by phone, then you should call your insurance and see if they have received the claim. Call the phone number on the back of the card and have all of your insurance info available. They will need to know which dates of service you are inquiring about and the amounts that were charged out. Here is a list of questions that can be helpful to ask insurance to aid in processing the claim.

Have you received a claim for this particular DOS?
Has this claim been processed?
Why have I not received an EOB for this claim in the mail?
Is there additional information that the insurance needs before they can process it completely? Also, has a request for information been sent to Dr. Spencer’s office?
Can you describe the specific information that is still needed?
Please speed up this process as I am waiting on the reimbursement.

If the insurance is still processing the claim, call them back again, but wait a week so that they have enough time to finish. When the insurance has finished, they should send the patient a check for their reimbursement with an EOB explaining why and what they paid.

After our patients are fit with their oral sleep appliance, they typically will never have to submit any more claims. We charge out the entire price of the appliance at the time of them receiving their splint. This means that they will submit that claim and all of the other office visits will be part of that claim. All of the follow up visits and adjustments to the appliance will be covered under this initial fee unless other changes occur or other arrangements are discussed.

Complications with your claims

For a definitions and complete insurance explanations refer to the Glossary.

If you have lost the claim form that we gave to you or you did not receive a form, we can simply reprint another for you.
Once you have submitted the claim, call your insurance (use the customer service or claims phone number on the back of your card). If there is no phone number look through your insurance information or online to find who to talk to about the claim. When you call, ask if they have received a claim for those dates of service. If they have not yet received it, then you might try faxing it to them. Also, make sure that you have sent it to the correct address. Ask if it is still being processed or if it has been received. If it is still being processed then check back about a week or two later. Ask if there is any additional information that is needed. Send this information to them.
If they have requested information from us, it is likely that it will take about a month for them to receive this info and completely process it.
If your insurance has denied the claim, discuss the reasons for denial with them. Find out exactly what information they are lacking or still need and what you need to do to appeal the denial. If they need anything more from our office, contact us or have them send (mail or fax) a record request to us. Many times insurance will deny the initial submission. They will have a variety of different reasons, but if you continue to endure the process and give them everything they request, they will eventually reimburse.
If they have denied the claim based on the fact that they are coded as medical and this is a dental office, let them know that these procedures are medical procedures and they should be coded as medical. Let them know that the doctor is a dentist (DMD) and works with the treatment of Sleep Apnea and TMJ, which are both medical treatments rather than dental. If you have submitted to your dental insurance make sure that the coding is dental.
If they have denied it based on the wrong coding, you will need to speak with us. We continually update our coding. But, occasionally, they change their standards or we may have made a mistake. If they need a code modifier then we need to know. Any other coding problems, please speak with us.
It is always a good idea to call your insurance if you have questions on the status of a claim. They will be able to tell you if they received the claim for each date of service and can explain all terms and conditions.
If insurance tells you that the doctors office has to submit everything it is not always true. The insurance companies have become familiar with this process and forget that patients may submit everything for themselves. The only processes that must be submitted by our office is most prior authorizations that are required, or any paperwork that needs to be signed by the doctor. Most regular visits will not need to be processed by our office. (Check the Individual Insurances link to see if your insurance company requires special processing.)

Individual Insurances Sleep Apnea

This section is to aid our patients with their specific insurance. This is to help them know which steps to take before beginning treatment and to have an idea of the expectations from their personal insurance. These are general rules for the particular insurances listed and the criteria changes constantly. It is still important to call your insurance and know what they need before you schedule.

Medicare

Before Coming In:

We are providers for Medicare. At your first appointment we will need a copy of your Medicare card(s) and if you have a secondary insurance or Medicare supplement plan, we will need to copy that card as well. We will collect your Co-Pay at check out. If you have a secondary insurance, then there should be no Co-Pay, and therefore we will not collect any money from you. We have found that Medicare covers most of the procedures here in our office, but it can take quite some time for the final results from Medicare to come back to our office (6 months to a year). It is important for our patients to know that they will be responsible for any charges and fees that Medicare doesn’t pay. We will bill our patients the remaining balance after Medicare is done paying on the case. For our sleep apnea patients this is usually a very small amount because Medicare has been paying on almost everything. Each case is different and we are not able to guarantee benefits.

We have our Medicare patients sign an Advanced Beneficiary Notice (ABN) form. This is a form stating that the patient will be billed and responsible for the treatment that is not paid by Medicare. TMJ is not a covered Medicare benefit. Medicare has been paying on some of the TMJ claims that we have submitted, but there is no guarantee that they will continue to do so. Patients will be responsible for any amounts that Medicare will not pay on. Only after we have exhausted all options in attempt to receive reimbursement from Medicare, will we then bill our patients for the remaining amount.

True Blue

Before Coming In:

True Blue has many requirements before actually being seen in our office. They usually require every visit to be prior authorized. They provide forms on their website that can be downloaded for this purpose. The prior authorization must come from the referring provider or the patient’s primary provider for TrueBlue. We are happy to fill out the form and send it to the referring provider to begin this process, but we are unable to actually submit it to TrueBlue.

True Blue also requires an office co-pay of $20.00 at each visit. We will expect this co-pay and the co-pay for the appliance when you are fit with it.

TrueBlue also authorizes its patients to only come in for a set amount of time, or a set amount of appointments. They will usually give this information in the approval letter. It is very important to remember when appointments are authorized, otherwise they will not pay anything towards those appointments. We try to track these date limitations, but it can be missed on occasion. It is always easy to call the insurance to ask if you are still authorized. We can also extend that authorization if needed. We will only perform this process after we have verified that further treatment is indicated. Sometimes this extended treatment authorization will need to be submitted by the referring doctor. We can help you with this information when the time comes.

United Health Care

Before Coming In:

We are considered an out-of-network provider. There is usually not much that is required from United Health Care before coming in to our office. It is best to call them and find out if your policy will have any benefits for you towards this treatment.

Many times after the patient has come in for treatment and submitted claims we have found that UHC won’t always pay on claims that are submitted the first time. It usually takes a few submissions and to call and work with them and send in the same, complete information for them to pay as they said they would. Don’t give up on them, if you submit everything that they ask for, you will hopefully be reimbursed. It just takes endurance.

Tricare/Triwest

Before Coming In:

As with all Tricare procedures and office visits, everything will need to be prior authorized. They will need to have each office visit authorized and approved before the patient comes in to see us. We are happy to help in initializing this process for the first appointment, but we are not able to actually submit the information. Before the patient is actually seen by us, they must have a referral sent by the referring doctor. This is a specific form that the referring doctor’s office can find on the Tricare’s website. (We also have a copy on hand and are able to fax it to the referring doctor’s office.) Once this form is sent in to Tricare they will usually need about a week to approve the request. Once it is approved, we can then see the patient. Many times the patient will have a time limit on dates that the patient can be seen, or they have a limit to only so many visits before the appointments will need to be authorized again.

After the treatment is approved, we need to verify if the actual splint is approved or not. In the approval letter from Tricare, they will define what is already approved or not. If the splint, CT scan, MRI, or treatment is not stated as approved, then you will need to call them to see if prior authorization is needed for that specific code (see Prior Authorizations under Before Coming In link).

We have all of our Tricare/Triwest patients sign a waiver form. This is a form stating that the patient will be billed and responsible for the treatment that is not paid by Tricare/Triwest. Only after we have exhausted all options in attempt to receive reimbursement from Tricare/Triwest, will we then bill our patients for the remaining amount.

Tricare authorizes its patients to only come in for a set amount of time, or a set amount of appointments. They will usually give this information in the approval letter. It is very important to remember how long the appointments are authorized for otherwise they will not pay anything towards those appointments. We try to track these authorization limitations, but on occasion it can be missed. It is always easy to call the insurance to ask if you are still authorized. We can also extend that authorization if needed. We will only perform this process after we have verified that further treatment is indicated. Sometimes this extended treatment authorization will need to be submitted by the referring doctor. We can help you with this information when the time comes.

Blue Cross of Idaho:

Before Coming In:

We are considered an out-of-network provider. We have found that they don’t usually require any prior authorizations for office visits. Prior authorizations are almost always required for any imagery (CT scan, MRI, etc.). Each policy is different in what it requires. It is best to call and talk to your insurance to see what your requirements are. The authorizations for imagery are done through a company called NIA and they require that we must fill out the application and submit it for our patients. We are happy to do this. It usually takes about 3 days for turnaround for the actual reply and then a little longer for any appeals or requested information to be processed. It is best to schedule a few weeks out so that the necessary authorizations can be in place for the appointment.

Regence Blue Shield of Idaho

Before Coming In:

We are considered an out-of-network provider. No prior authorizations are usually needed for office visits. Imagery such as CT scan or MRI may possibly need prior authorization. Always check with your insurance to know for sure.

We have found that Blue Shield does not usually allow the use of out-of-network waivers. We like to send out-of-network waivers to help our patients receive more reimbursement, but Blue Shield typically will only pay at the out-of-network rate for your treatment with us.

TAP Packet for Sleep Patients

We provide this packet for all of our patients that will be treated for sleep apnea. This is for the purpose of sending to your insurance company in an attempt to get better coverage. Typically we have our patients submit it to the insurance for prior authorization on their sleep appliance. The patient should also submit a copy of their sleep study and a copy of their referral to our office along with the contents of the packet.

The packet gives medical credibility to the necessity for the appliance to aid in the treatment of sleep apnea. We know that the packet is long, but it is necessary to send the entire packet along with the other information for the insurance to give it consideration and to approve it. Here is the actual list of everything needed to be completed before sending.

First call your insurance find out if a prior authorization is needed.
Ask your insurance if sleep apnea is a covered benefit on your policy.
Let them know that you will be sending information to them to authorize an oral appliance for the treatment of your sleep apnea. (Send only if they require information to be sent). Ask them what you will need to send for this process. Also ask for the direct address or fax number where to send it, the exact department, and who’s attention to send it to. You may fax or mail this.
If you have used C-PAP or have had a trial of C-PAP, let your insurance know that this oral appliance is an alternative to C-PAP and give them the reasons why you no longer can use the C-PAP. (This will make your case stronger).
Send all of the required information that they need to them plus this information provided. Make the information clear and complete.
Send a cover letter with this information and restate your purpose in sending the information. (We provided a sample cover letter for you to use as a guide for this).
Send a copy of your sleep study. We will try to provide you with one at your first office visit (if we forget, call us and we can get one to you).
Print out all of the following pages and fill in any necessary lines before sending.

We wish you the best of luck.

TAP Packet begins on the following page.

Sample Cover Letter

August 21, 2007

To: Blue Cross of Idaho
Attn:
(Address)

RE: (Patient Name)
ID#:
DOB: 8/21/2007

To Whom It May Concern:

I have been referred to the office of Jamison R. Spencer D.M.D. for the treatment of Obstructive Sleep Apnea (ICD-9 code 327.23). I am sending this packet of information for the predetermination on an oral appliance for treatment of my diagnosis and symptoms. I have had a trial of CPAP with Dr. _________ Polmonologist and found it to be difficult for me and that I am intolerant. (Expound on these details of why you are no longer using CPAP).

I would like to request a pre-determination of coverage for the sleep appliance (HCPC E0486 custom fit sleep appliance airway dilator) as well as an Out of Network Waiver (In-Out). (Only use Out of Network Waiver if you know that your insurance will accept a waiver, some insurances won’t).

I am including with this request a copy of my original sleep study, a description of the appliance, and the parameters for sleep appliance use. The purchase price of this appliance is $1800 and includes follow up care for one year.

I am seeking an in-out (out of network waiver) in order to be reimbursed at the in network rate as Dr. Jamison Spencer is the only provider in the geographical area who can provide the sleep appliance.

Dr. Spencer has credentials and unique training in the treatment of sleep apnea. He is a diplomate of the Academy of Dental Sleep Medicine. The practice parameters of the American Academy of Sleep Medicine state that oral applicaces for sleep apnea should be fit by a dentist specifically trained in this area.

Thank you for your consideration of the following information,

Signature
Your name

This is a sample letter that can be given to the referring provider as an example. Or the referring provider can simply send a referral to us. This letter should be accompanied by your sleep study, and chart notes from the referring doctor if applicable/available.

Name of Insurance Company
Address

Name of Patient:
Policy #:
Date of Birth:

To Whom It May Concern:

I have referred my patient, _________________, for evaluation and fitting of a sleep appliance/airway dilator for treatment of (name/DX of sleep disorder).

This treatment option is indicated for (patient’s name) as he/she (is CPAP intolerant, desires a less invasive/permanent alternative to surgery, etc.). CPAP is not indicated because ( name of patient ), (sleep study reveals problem best treated with an airway dilator, etc.)

Thank you,

(Doctor’s name)

Dr. Jamison R. Spencer
Member of the American
Academy of Sleep Medicine
Credentialed Member of the
Academy of Dental Sleep Medicine

To Whom It May Concern:

Your insured has been referred to our office by their physician for evaluation and treatment with an oral appliance for their obstructive sleep apnea. Oral appliances are second only to CPAP in the treatment of obstructive sleep apnea and are recommended in mild to moderate OSA at the direction of the patient’s physician. Oral appliances are indicated in all cases of CPAP intolerance, regardless of the severity of the OSA.

This patient has not been referred for, nor are they being treated for, any type of temporomandibular disorder (TMJ).

This patient has been referred to our office because of our special interest and training in oral appliances for sleep disorders. Our office only sees sleep apnea patients by referral from a physician.

The Thorton Adjustable Positioner (TAP), a mandibular repositioning appliance, is FDA approved for the treatment of sleep apnea (FDA 510K #K972061).

The following packet of material is provided to help inform the reviewer of this case and update them on oral appliance therapy for obstructive sleep apnea. If you have any specific questions regarding this case, or oral appliance therapy in general please call our office and we will be happy to speak with you personally.

Sincerely,

Dr. Jamison R. Spencer

Enclosures: (one or more of the following)

American Academy of Sleep Medicine (formerly ASDA) “Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances”

American Academy of Sleep Medicine (formerly ASDA) “Oral Appliances for the Treatment of Snoring and Obstructive Sleep Apnea: A Review”

“Evaluation of Variable Mandibular Advancement Appliance for Treatment of Snoring and Sleep Apnea” CHEST Vol. 116, p. 1511-1518, December 1999

“Treatment of Sleep Apnea: Unmet Needs” CHEST Vol. 116, p. 1501-1503, December 1999

NIH publication No. 95-3803 “Sleep Apnea: Is Your Patient At Risk” p. 4-5.