How to fill out and submit your claim

(If you need to authorize visits prior to your appointment please see the 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.  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:

1. 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).
2. Your signature.
3. Date (that you are signing the claim, NOT the date of service).
4. Your date of birth.
5. 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)

If your TMJ symptoms are due to an accident:

On every claim, you must also include basic accident information. This
portion is located in the upper right section of the claim form.
You will need to include:

1. If this claim is in regards to an accident related injury (check yes or no)
2. The date of the accident

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 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?  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 they paid what they paid.

The patient will continue to submit claims for each visit.  We are willing to help with any complications and troubles in submitting.  If the insurance requires more information we will always try to do our best to help process the claims to your greatest benefit. 

Complications with your claims

For definitions and complete insurance explanations refer to the Glossary.
•    If you have lost the 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 information 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 may 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 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.  Usually we continually update our coding and should be accepted by them. But, occasionally, they change their standards.  If they need a code modifier then we need to know and add on to the code for you.  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.)