Insurance Guidelines

Not accepting assignment means you pay for doctors time in full and you file insurance claim so that the insurance reimburses you. This allows Dr. Yount to manage your chronic pain without restrictions or limitations on success on your needs for pain management.

Every policy is different. Primary responsibility to what is covered is chosen by you or your HR department. We are happy to assist you in obtaining re-imbursement, but we are not responsible for how "your" contract decides to reimburse.

Introduction

  1. Not in-network
  2. Pay time service
  3. Claim forms
  4. File re-imbursement
  5. Appeals: we assist

Substantiation Science

  1. Joint muscle system not teeth
  2. Orthopedic care not dentistry
  3. Chronic pain not acute pain
  4. Team support not single tx

Responsibility

  1. Ours:
    1. Letter Medical Necessity
    2. HICFA 1500
  2. Yours: patient:
    1. changes coverage
    2. personal info
    3. Lapse coverage
  3. Insurance Coverage
    1. Pay doctor's fee up front in full
    2. Mail copy HICFA & LMN to medical insurance
    3. Follow up call in 30 days
    4. Call every week until they re-imburse

Pre-authorization

  1. Pre-authorization exam
  2. In-network coverage
  3. Pre-authorization orthotic
  4. Inform them this is chronic pain & chewing system orthopedics

Specialty Care

  1. Document mod severe damage
  2. Home care tried (soft diet, good posture, anti-I)
  3. General dental or medical care tried
  4. Acute pain therapies tried

Changes

  1. Coverage
  2. New plan year

Claims

  1. File claim
  2. 30 days mark calendar
  3. Check received or appeal first
  4. Check received or second appeald
  5. On second appeal-call Courtney for assistance

Appeals

  1. Not Responsible: we are not responsible for decisions of “your” ins. co.
  2. Courtesy: As a Courtesy to you, we will assist you in appeals process.
  3. Active patient: you are scheduled and actively seeking chronic pain care
  4. Pursue: any and all avenues to help you procure re-imbursement for your services here RFPC

Insurance Information:

  1. Inform “your” insurance companies going out network
  2. Out of Network: payment expected time service
  3. Provide: Letter Medical Necessity (LMN)
  4. Provide: Insurance claim form (HICFA)
  5. File HICFA & LMN
  6. Place calendar 30 days notice

In Network Benefits with “Your” Policy

  1. Must have out-network benefits
  2. Must cover chronic pain therapy
  3. Must cover joint/muscle damage
  4. Must cover orthopedic therapy
  5. Must cover chewing system orthopedics
  6. Covers Integrative Therapies chewing system

Applying In-Network Benefits: We can Assist

  1. Ask “your” for policy exclusions in TMJ
  2. Request list providers “your” policy has for care TMD
  3. Differentiate:
    1. Non-surgical care verses surgical care
    2. Acute pain verses chronic pain
    3. Board certified &residency trained in Orofacial Pain
    4. Mild damage verses moderate-severe damage care
  4. List may contain:
    1. Dentist w/ weekend training TMD
    2. Oral surgeons w/ surgical train
    3. Dentist using nonscientific methods treat TMD
  5. Call the providers ask if they supply non surgical care for moderate to severe damage TMD cases w/ chronic pain team
  6. We cannot predict “your” insurance company response or decisions

Pre-authorization exam requested by “your” insurance company

  1. Call ins co to verify requested pre-cert for exam
  2. The examination code for detailed chronic pain exam:
    1. 99244 for pedo
    2. 99245 for adult
  3. Your research of “your” pains, coaching and teaching science, and treatment planning of “your” complex case
    1. 99215-BCBS
    2. 99205 -UHC or CIGNA
  4. Inform “your” insurance company that “your” treatment planning will dictate the diagnostic & treatment codes, included in LMN
  5. Send w/ each of your claims (HIFICA) the LMN so they have access to treatment codes

Surgical Insurance confusion: Confusion in terms: Conservative Therapies vs Home care: 1) Insurance companies and surgeons have used term conservative therapies incorrectly. 2) What they really mean is they failed home therapies. 3) Surgeons have justified need for surgery by telling insurance company, "Failed Conservative Therapy" 4)The better term is home therapies. 5) "Conservative Therapies" implies chewing system orthopedics ( PT, Bio, orthotic, Patient changing health habits) 6) Failing chewing system orthopedics means failing orthotic, physical therapy, biofeedback, health habits changes 7) Failing chewing system orthopedics rarely happens !!!! 8) So insurance approval of TMJ surgery should rarely happen

Not accepting assignment means you pay for doctors time in full and you file insurance claim so that the insurance reimburses you. This allows Dr. Yount to manage your chronic pain without restrictions or limitations on success on your needs for pain management.

Every policy is different. Primary responsibility to what is covered is chosen by you or your HR department. We are happy to assist you in obtaining re-imbursement, but we are not responsible for how "your" contract decides to reimburse.

Introduction

  1. Not in-network
  2. Pay time service
  3. Claim forms
  4. File re-imbursement
  5. Appeals: we assist

Substantiation Science

  1. Joint muscle system not teeth
  2. Orthopedic care not dentistry
  3. Chronic pain not acute pain
  4. Team support not single tx

Responsibility

  1. Ours:
    1. Letter Medical Necessity
    2. HICFA 1500
  2. Yours: patient:
    1. changes coverage
    2. personal info
    3. Lapse coverage
  3. Insurance Coverage
    1. Pay doctor's fee up front in full
    2. Mail copy HICFA & LMN to medical insurance
    3. Follow up call in 30 days
    4. Call every week until they re-imburse

Pre-authorization

  1. Pre-authorization exam
  2. In-network coverage
  3. Pre-authorization orthotic
  4. Inform them this is chronic pain & chewing system orthopedics

Specialty Care

  1. Document mod severe damage
  2. Home care tried (soft diet, good posture, anti-I)
  3. General dental or medical care tried
  4. Acute pain therapies tried

Changes

  1. Coverage
  2. New plan year

Claims

  1. File claim
  2. 30 days mark calendar
  3. Check received or appeal first
  4. Check received or second appeald
  5. On second appeal-call Courtney for assistance

Appeals

  1. Not Responsible: we are not responsible for decisions of “your” ins. co.
  2. Courtesy: As a Courtesy to you, we will assist you in appeals process.
  3. Active patient: you are scheduled and actively seeking chronic pain care
  4. Pursue: any and all avenues to help you procure re-imbursement for your services here RFPC

Insurance Information:

  1. Inform “your” insurance companies going out network
  2. Out of Network: payment expected time service
  3. Provide: Letter Medical Necessity (LMN)
  4. Provide: Insurance claim form (HICFA)
  5. File HICFA & LMN
  6. Place calendar 30 days notice

In Network Benefits with “Your” Policy

  1. Must have out-network benefits
  2. Must cover chronic pain therapy
  3. Must cover joint/muscle damage
  4. Must cover orthopedic therapy
  5. Must cover chewing system orthopedics
  6. Covers Integrative Therapies chewing system

Applying In-Network Benefits: We can Assist

  1. Ask “your” for policy exclusions in TMJ
  2. Request list providers “your” policy has for care TMD
  3. Differentiate:
    1. Non-surgical care verses surgical care
    2. Acute pain verses chronic pain
    3. Board certified &residency trained in Orofacial Pain
    4. Mild damage verses moderate-severe damage care
  4. List may contain:
    1. Dentist w/ weekend training TMD
    2. Oral surgeons w/ surgical train
    3. Dentist using nonscientific methods treat TMD
  5. Call the providers ask if they supply non surgical care for moderate to severe damage TMD cases w/ chronic pain team
  6. We cannot predict “your” insurance company response or decisions

Pre-authorization exam requested by “your” insurance company

  1. Call ins co to verify requested pre-cert for exam
  2. The examination code for detailed chronic pain exam:
    1. 99244 for pedo
    2. 99245 for adult
  3. Your research of “your” pains, coaching and teaching science, and treatment planning of “your” complex case
    1. 99215-BCBS
    2. 99205 -UHC or CIGNA
  4. Inform “your” insurance company that “your” treatment planning will dictate the diagnostic & treatment codes, included in LMN
  5. Send w/ each of your claims (HIFICA) the LMN so they have access to treatment codes

Surgical Insurance confusion: Confusion in terms: Conservative Therapies vs Home care: 1) Insurance companies and surgeons have used term conservative therapies incorrectly. 2) What they really mean is they failed home therapies. 3) Surgeons have justified need for surgery by telling insurance company, "Failed Conservative Therapy" 4)The better term is home therapies. 5) "Conservative Therapies" implies chewing system orthopedics ( PT, Bio, orthotic, Patient changing health habits) 6) Failing chewing system orthopedics means failing orthotic, physical therapy, biofeedback, health habits changes 7) Failing chewing system orthopedics rarely happens !!!! 8) So insurance approval of TMJ surgery should rarely happen

Pearls of Pain

Comorbid conditions
1) Neck pain: is associated with muscle bracing, posturing, reciprocal contraction jaw system 2) Headaches: head pain is associated with muscle bracing, posturing, reciprocal contraction jaw system 3) Traumas: Falls, Blows head, blows jaw, MVA increase in jaw or neck pain
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