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 much quicker 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 fees 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 TMJ/TMD, which is not considered a dental condition, but instead is considered a medical condition. For this reason we are 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 difficult for us to submit to the insurance for you. Therefore, we help our patients to submit to their insurance which allows their insurance to reimburse them directly. 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 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:

• 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 for treatment, it will be enough for the insurance. It is helpful to have a referral when working with insurance because insurance companies will be more willing to reimburse if we have sufficient proof to show these symptoms.
• 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).  We can take the x-ray here if you don’t already have one.  Dr. Spencer will need an updated one for the first appointment. 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.
• 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 there is an exclusion for the treatment of TMJ and what would be covered as you come in for treatment.
  • 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 with this expertise. Also tell them that you would like them to consider an in-network rate for this reason. This can be a very strong point for your case when your insurance is questioning whether they will reimburse or not.

Call our office to schedule an appointment. We will ask about your symptoms and how long you have been experiencing them. Your appointment will also 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 within 24 hours of the appointment.   
 
Prior Authorizations

Many 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
      Blue Shield

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 the 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, they can always change their mind. 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:
    99203        $149.00      Initial examination and Consultation
    70355        $99.00        Panoramic X-ray (only when needed)

First or Second Appointment (only if determined necessary by the doctor):
    70486        $570.00      CT scan (only if indicated by the doctor).     
    21076        $25.00        Study Models/Impressions (when further treatment    
                                             is indicated).

*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. 


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 to fax it, the mailing address, a contact name, their direct phone number and extension, how long the processing time is, what department to direct it to and a reference number (they might not have one assigned yet).
• Mail 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
• Information on the Appliance (s)--We can give this to our patients upon request.
• 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 will only pay at the out-of-Network rate when we provide 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 it.  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. If this is the case, they will generally send us a records request.  Have them give you a time frame for when you will receive an answer.  

Any questions or concerns, please call us!!!