Don’t Fear Medical Claims

At a recent medical billing class I overhead a gal behind me murmur ” time for me to retire !” She was starting to feel pretty overwhelmed by all of the  medical billing information. I started to feel nervous myself hearing that dental offices will have to start billing medical as primary beginning as early as 2020! To prepare myself, I have been taking as many medical billing classes as I can. A lot of the procedures  you can now bill  medical for, such as sleep apnea or TMJ, do not apply to the endo office I work at. We can only bill for endo  when it’s needed after an injury, or for an apicoectomy.

Oral surgery offices, however,  are billing medical for implants and extractions and getting reimbursed.  The keywords for a medical narrative are “infection in the jawbone” as medical will pay for treatment related to inflammation and infection. More policies are offering extra dental cleanings for pregnancy and diabetic patients. Insurance companies are acknowledging the fact that systemic infections can affect the oral cavity. Dentists of the future will be known as “oral physicians.”

The problem most dental offices have is that they need the software to submit a medical claim or they can hire a third party biller, such as eAssist. Medical claims are required to be on a special form (CMS 1500) and it needs to be sent electronically because these scan correctly. Handwritten claims or comments are not accepted. Paper claims are usually not accepted although recently I  found out that Aetna has an oral surgery claims department and they will accept a dental claim for covered medical procedures, such as a necrotic pulp due to trauma. I did have to mail the claim with x-rays and a detailed narrative regarding the trauma in the patient’s handwriting. The patient had extensive medical claims and met his deductible so this particular claim did actually get paid. Some do not because a deductible has to be met first but by sending the claim to medical, this helps the patient meet their deductible. I recently learned that you can also bill HMO medical, they may reject it several times but keep appealing stating the dentist is a physician treating an infection in the jawbone!

On big surgery cases the reimbursements can be substantial. If multiple extractions and implants are done with an anesthesiologist, the medical will pay for this saving the patient a lot of money and saving his dental coverage for the crowns and other dental work. If your office assists in the billing of the medical claim, the patients will see this value added service and appreciate the extra time it takes.

Cigna states on their website that patients can receive 100% in  medical reimbursements for copays or coinsurance for certain dental procedures related to maternity, stroke, cardiovascular disease, diabetes, head and neck cancer radiation, organ transplants and chronic kidney disease! All of the above conditions would allow  perio treatment and maintenance to be covered under medical. For maternity, not only perio and cleanings would be covered but oral evaluations and  emergency palliative treatment as well. Fluoride application and varnish and sealants would quality for medical reimbursements for chronic kidney disease, organ transplants, and head/neck cancer radiation.

Another interesting note about medical is that you want to be in the network with medical. Their UCR allowances are usually more than what dental insurance companies pay and usually above  your regular fee! How crazy is that?! Completely opposite of dental insurance allowances! The doctors will need to make sure they are taking notes in the SOAP format because some consultations will require chart notes to be submitted and all medical claims are subject to review.

So, don’t fear medical. It can potentially pay for more treatment that the patient would not be able to afford (not all medical plans have a high deductible).  What is being viewed as a headache may turn out to be a blessing in disguise!

eAssist Helpful News and Billing Tips; Edition #112


  • Do you have, or would you be willing to create, a “cheat sheet” for dental offices? A checklist, or series of questions, which would help us determine whether or not a claim can be submitted to medical, and whether the claim should be submitted to medical instead of or before dental?

  • Awesome article – I learned greater appreciation for medical coverage of treatment done by a Dentist.

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