Ask the Expert...Medical Billing Basics - Part I

Over half of the support calls received by the staff of Insurance Solutions Newsletter involve basic medical billing questions. Understandably, the thought of billing their first medical claim can be overwhelming for dental business staff. Even so, dental practices across the country are biting the bullet as they find the need to bill medical insurance plans for accident-related dental services, surgical extractions, biopsies, TMJ orthotics, sleep apnea appliances, etc. Unfortunately, all too often, medical claims are denied simply because the fundamentals of medical billing are not understood. To that end, we have compiled a list of frequently asked questions to assist dental teams in understanding some of the fundamentals of medical billing. The purpose of this article is to focus on and answer questions about which dental procedures are sometimes covered by medical plans, how to research medical benefits and obtain preauthorization/predetermination, how to request a network gap exception, and where to obtain medical claim forms.

Dental Procedures Covered by Medical Plans

Q. What procedures performed by dentists are covered by medical plans?

A. Medical coverage is determined by the specific language contained in the patient’s medical policy and the ability of the provider of service to support medical necessity. The following services may be covered under your patients’ medical plans:

Often covered—oral pathology services (i.e., biopsies and excision of lesions) and trauma-related services

Sometimes covered—extraction of bony impacted teeth, sleep apnea appliances, oral orthotics and related TMJ services, dental services related to oral manifestations of a systemic disease (e.g., xerostomia and rampant decay due to Sjogren’s syndrome), services related to cancer and radiation therapy (e.g., pre-treatment oral evaluations, preradiation extractions, pre- or post-radiation fluoride trays, etc.), and congenital defects (e.g., cleft palate)

Rarely covered—simple and surgical extractions, socket preservation grafts in preparation for implants, dental implants that are not related to a traumatic accident or congenital defect, and periodontal procedures for patients without a strongly-associated systemic disease

Q. Will medical plans pay for procedures to treat dental conditions caused or exacerbated by medications or systemic disease (i.e., medications/diseases causing xerostomia, or diseases such as diabetes, gastroesophageal reflux disease [GERD], etc.)?

A. Coverage for these services varies from carrier to carrier. It is necessary to check each patient’s medical policy to know its specific guidelines. Coverage may be available but only if the patient’s condition meets the level of medical necessity that his/her plan requires to obtain coverage. Each medical plan will have specific requirements that the documentation in the patient’s record must support for diabetes-related services to be covered. In other words, not all patients with diabetes will have dental services covered by their medical plan. Some will in certain circumstances, but many won’t.

Q. Should we submit restorations caused by GERD to the patient’s dental plan or medical plan?

A. If the patient’s medical plan provides coverage for dental restorations due to GERD, submit the claim to medical first. When dental restorations are required as a result of a systemic disease or medication, they can be very extensive. Reimbursement may quickly exhaust the maximum benefits available under most dental plans. By submitting the claim to the patient’s medical plan first (after verifying that benefits are available), you may be able to preserve the dental benefits for other dental services that are not related to the medical condition.

Q. Is it appropriate to bill medical insurance for periodontal procedures if the patient does not have diabetes or some other medical condition associated with periodontal disease?

A. There is nothing that prohibits one from submitting a claim for periodontal services to a medical plan as long as the claim is correctly coded and does not misrepresent the reason for the services rendered. However, periodontal procedures are not likely to be covered if the patient has no associated risk factors such as heart disease, history of stroke, pregnancy, etc., or if there is no medical condition (or medication) that has exacerbated the periodontal condition. Even if the patient’s medical plan provides benefits for periodontal services when a related medical condition exists, the plan may require a referral letter from the patient’s primary care physician to justify reimbursement.

Q. How do we determine if a procedure will be covered by the patient’s medical plan?

A. The first step is to go to the medical carrier’s website to verify if benefits are available online. Most major medical carriers have their coverage guidelines available on their website. Search for “medical policies.” An alphabetical listing of the carrier’s policies typically appears, allowing you to select the policy you would like to review. If you are unable to access a patient’s medical benefit information online, contact the medical carrier by phone. Before making the call, make note of the procedure codes (CPT), diagnosis codes (ICD-9), and questions you need to ask during the call. The diagnosis codes are key to supporting medical necessity and often determine whether or not coverage is available. Diagnosis codes can be found in a variety of ICD-9 books that are available through the American Medical Association and other private vendors such as Ingenix or PMIC. ICD-9 diagnosis codes are also available online free of charge at Newsletter subscribers can obtain a phone preauthorization template by emailing with “Medical Phone Template” in the subject line.

Obtaining Medical Preauthorization

Q. Will medical carriers preauthorize services performed by dentists?

A. Medical preauthorizations can often be obtained by phone for services that are frequently covered. However, some medical carriers require the submission of additional documentation for more detailed or higher cost treatment plans. In these instances, it may take up to 30 days to receive an answer regarding coverage. If the patient’s medical plan asks you to submit additional documentation in writing, ask where and how the preauthorization should be submitted. Some will allow you to fax the information. Others will want it mailed. Also ask how much time it will likely take to obtain an answer so you can plan accordingly.

Unlike dental billing protocols, medical predeterminations cannot be submitted on the medical claim form. When not available by phone, preauthorization requests should be submitted in a letter format (see sample on right).

Q. Should we always obtain a preauthorization from the patient’s medical plan for any procedure we plan to bill medical?

A. It may not be necessary to obtain a preauthorization for every procedure you intend to bill medically. However, it is a good idea to contact each patient’s medical carrier to ask if a particular procedure is a covered benefit under the patient’s medical policy and if it requires preauthorization or a referral from a primary care physician. Using a medical preauthorization phone template reminds staff what questions to ask and what information the medical carrier may require for payment.

Q. When submitting a preauthorization request, will the medical carrier tell us exactly what it will pay so we will know how much the patient will owe?

A. Some medical preauthorizations may state that the service is covered and payment will be based on the carrier’s usual and customary fee schedule. When this occurs, you will need to contact the medical carrier to ask if your fees for the preauthorized procedures are within the plan’s fee schedule. If you are not a participating provider and have not agreed to accept assignment (on the medical claim form), you should be able to balance bill the patient for the amount not covered by his/her medical plan. Even so, we strongly encourage dental practices to collect full payment at the time of service from patients whose procedures they are billing to medical insurance and instruct the carrier to reimburse the patient directly.

Other Medical Billing Basics

Q. Are dentists required to bill medical plans the same fee that they bill dental plans, or can they charge a higher fee when submitting a claim to a medical plan?

A. Dentists must submit the same fee to an insurance carrier (whether it be a medical or dental carrier) that they are charging the patient. Charging a higher fee to an insurance carrier than you intend to charge the patient could be considered insurance fraud.

Q. Do dentists need to participate in the patient’s medical network in order to receive payment for services?

A. The answer depends on the carrier. Some medical carriers will only pay for services performed by in-network providers. Other carriers allow payment to out-of-network providers. It is important to ask this question when calling the patient’s medical plan to inquire if benefits are available for the treatment planned.

Q. Our doctor (a periodontist) extracted a patient’s teeth because she was undergoing hemotherapy. The patient maxed out her dental insurance plan and asked us to submit the claim to medical. Her medical plan rejected the claim because of the “type” of provider that performed the service. Do most medical carriers require a specific type of provider to do the treatment?

A. Some medical carriers limit payment to in-network providers, and some limit participation to oral surgeons. As such, we urge dental practices to contact the medical carrier for preauthorization prior to treatment and specifically ask if coverage is limited to in-network providers or certain specialties.

Q. We rarely receive medical payment because we are not in the patient’s medical network, which doesn’t accept general dentists. Anything we can do about this?

A. Request a “network gap exception,” which may be available if there is no other network provider within a reasonable distance who is qualified to perform the services. For example, only a dentist is qualified to provide an oral sleep apnea appliance or a TMJ orthotic. If the medical network provides a benefit for these services but does not accept dentists in their network, then a “network gap exception” should be requested prior to providing the service. If the carrier does not allow a network gap exception, have the patient contact his/her Employee Benefits Manager for assistance.

Q. Does a network gap exception pay the same as if we were in-network?

A. The answer depends on the carrier. Some may pay you as an in-network provider and require you to take the network write-offs. Others may pay you as an out-of-network provider even though the plan normally only pays benefits to in-network providers.

Q. If we are an out-of-network provider, is there any way to have the medical payment sent to us? We have worked long and hard on some claims only to have the payment sent to the patient. Some patients keep the check even after we call and ask them to endorse it to us.

A. We always recommend that dental practices collect their full fee from the patient at the time of service when billing medical plans. Where the check is mailed will vary depending on the medical carrier’s policy and may depend on state or contract law. Some state insurance laws require carriers to pay out-of-network providers directly if the patient signs the assignment of benefits section of the medical claim form. However, some medical plans are exempt from such laws due to their organizational structure/business model.

Q. Will medical carriers coordinate benefits with dental plans if coverage is available under both?

A. Most medical and dental carriers will coordinate benefits between medical and dental policies as long as there is no non-duplication of benefits clause in the contract. The coordination of benefits process between medical and dental is similar to coordination between two dental carriers. Claims are typically submitted to the medical insurance first. The medical plan’s explanation of benefits is then sent to the dental plan.

Q. If a procedure is covered under the patient’s dental insurance and the spouse’s medical insurance, can we bill both plans separately? Can the patient receive payment from both?

A. You must inform both carriers if you are submitting the claim to both so they can coordinate benefits.

Q. If a medical plan covers a service but it is applied to the patient’s deductible, can we then bill the dental plan? Does the patient have the choice of which plan to bill first?

A. The medical and dental carriers will determine which plan is primary. This may be regulated by state insurance laws or contract language. Typically, most dental plans will not process a claim for a procedure that may be covered under medical until the medical carrier has first considered the claim. After the medical plan processes the claim, submit the claim to the dental plan for coordination of benefits.

Q. Where can we obtain medical claim forms?

A. Some practice management software vendors provide the CMS-1500 medical claim form as part of their practice management system. Paper claim forms can be purchased from the American Medical Association and most major office supply stores and online vendors (i.e., Office Max, Quill, etc.).

Q. Our practice management software has a medical claim form, but it prints in black and white. A claim was recently returned because the medical carrier requires a typed red-ink form. Is this common?

A. Some medical carriers will only accept a paper claim if it is typed on an original redink CMS-1500 form. Send a self-addressed stamped envelope to the following address and we will send you four original red-ink medical claim forms free of charge:

Insurance Solutions Newsletter

Q. Our practice management software will not print a medical claim form. If a medical carrier requires the CMS-1500 claim form to be typed, is there a computer template available so we can use our printer?

A. If your practice management software vendor does not offer a medical claim form, there are several software applications available on the internet that allow users to complete a printable medical claim form online. Two sites to consider are and

Q. Is it true that we can use dental CDT procedure codes on medical claims?

A. Some medical carriers will accept dental CDT procedure codes when there is no specific medical CPT code to describe a dental service. Medical coding guidelines state that if there is a specific CPT code that accurately describes the service performed, then that is the code that should be submitted on the medical claim form. If there is no specific CPT code, submit the more specific HCPCS code. (Dental codes are part of the HCPCS coding system.) There are many services that dentists perform that do not have a specific CPT code. For example, currently, there is no specific CPT code to describe fillings, crowns, buildups, root canals, apicoectomies, extractions, etc. The best CPT code to report these procedures is 41899 (unlisted dentoalveolar procedure), which requires a narrative that describes the service actually performed. When performing these procedures, it is best to report the appropriate CDT code since it more clearly describes the service rendered.

Q. Are tooth numbers required on the CMS-1500 medical claim form? If so, where do we put them?

A. Some medical carriers require tooth numbers. Others do not. If a carrier requires tooth numbers one option is to list them in the shaded area in box 24 (above the procedure code). Use the JP modifier to inform the carrier that you are reporting teeth and then list the teeth. For example, reporting teeth numbers 1, 16, 17, and 32 would be listed in the shaded area of box 24 as “JP 1 16 17 32” (no commas are used—see claim example above). Another option for reporting tooth numbers is to list them in box 19 of the CMS-1500 claim form. Using this method, type the procedure code in box 19 followed by “teeth #1, 16, 17, 32.”

Reviewing the answers to the frequently asked medical billing questions above should help improve your success with medical claims. Watch for Part II in the next newsletter, which will address common questions about billing claims to Medicare, PECOS, global periods, and dental trauma/accident claims.