This section is to aid our patients with their specific insurance. This is to help them know which steps to take. The following directions should be helpful to know what some of the expectations are for the most common medical insurance carriers we have in Idaho. These are general rules and do change constantly.  It is still important to call your insurance and know what they need to have before you schedule.



Blue Cross of Idaho:

Before Coming In:
We are considered an out-of-network provider.  We have found that they don’t usually require any prior authorizations for office visits. Prior authorizations are almost always required for any imagery (CT scan, MRI, etc.). Each policy is different in what it requires. It is best to call and talk to your insurance to see what your requirements are. The authorizations for imagery are done through a company called NIA and they require that we must fill out the application and submit it for our patients. We are happy to do this. It usually takes about 3 days for turnaround for the actual reply and then a little longer for any appeals or requested information to be processed. It is best to schedule a few weeks out so that the necessary authorizations can be in place for the appointment.


BlueShield of Idaho:

Before Coming In:
We are considered an out-of-network provider.  No prior authorizations are usually needed for office visits.  Imagery such as CT scan or MRI will need prior authorization.  Always check with your insurance to know for sure.

We have found that Blue Shield does not usually allow the use of out-of-network waivers. We like to send out-of-network waivers to help our patients receive more reimbursement, but Blue Shield typically will only pay at the out-of-network rate for your treatment with us.


Medicare

Before Coming In:
 We are providers for Medicare. We will need a copy of your insurance card(s) at  your first visit and only need to take your co-pay at check out. If you have a  secondary insurance, then there should be no co-pay (or it is the co-pay that  the secondary requires), and we will not collect any money from you. We have found that Medicare covers some of the procedures here in our office, but it can take quite some time for the final results from Medicare to come back to our office (6 months to a year). It is important for our patients to know that they will be responsible for any charges and fees that Medicare doesn’t pay on. We will bill our patients the remaining balance after Medicare is done paying on the case.

We have our Medicare patients sign an Advanced Beneficiary Notice (ABN) form. This is a form stating that the patient will be billed and responsible for the treatment that is not covered by Medicare. TMJ is not a covered Medicare benefit. Medicare has been paying on some of the TMJ claims that we have submitted, but there is no guarantee that they will continue to do so. Patients will be responsible for any amounts that Medicare will not pay on. Only after we have exhausted all options in attempt to receive reimbursement from Medicare, will we then bill our patients for the remaining amount.   


Tricare/Triwest

Before Coming In:
As with all Tricare procedures and office visits, everything will need to be prior authorized. They will need to have each office visit authorized and approved before the patient is to come in to the office. We are happy to help in initializing this process for the first appointment, but we are not able to actually submit the information. Before the patient is actually seen by us, they must have a referral sent by the referring doctor. This is a specific form found on their website and can be easily downloaded. We are happy to fill out the information that we can and then it must be sent to the referring doctor for more information and they must submit it. This can take a few weeks, especially if the referring doctor is hesitant. Tricare will usually give the final decision to our office and the patient. Usually both, but not always. If treatment is approved, then we will try to call the patient and schedule them. If it is denied we will call the patient to let them know and see what the patient would like to have happen from there. We can send in an appeal, or try other routes. 

After the treatment is approved, we need to verify if the actual splint is approved or not. In the approval letter from Tricare, they will define what is already approved or not. If the splint, CT scan, MRI, or treatment is not stated as approved, then you will need to call them to see if prior authorization is needed for that specific code (see Prior Authorizations under Before Coming In link).

We have all of our Tricare/Triwest patients sign a waiver form.  This is a form stating that the patient will be billed and responsible for the treatment that is not paid by Tricare/Triwest.

Tricare authorizes its patients to only come in for a set amount of time, or a set amount of appointments. They will usually give this information in the approval letter. It is very important to remember how long the appointments are authorized for otherwise they will not pay anything towards those appointments. We try to track these authorization limitations, but on occasion it can be missed. It is always easy to call the insurance to ask if you are still authorized. We can also extend that authorization if needed. We will only perform this process after we have verified that further treatment is indicated. Sometimes this extended treatment authorization will need to be submitted by the referring doctor. We can help you with this information when the time comes.


TrueBlue

Before Coming In:
True Blue has many requirements before actually being seen in our office. They usually require every visit to be prior authorized. They provide forms on their website that can be downloaded for this purpose. The prior authorization must come from the referring provider or the patient’s primary provider for TrueBlue. We are happy to fill out the form and send it to the referring provider to begin this process, but we are unable to actually submit it to TrueBlue.

True Blue also requires an office co-pay of $20.00 at each visit. We will expect this payment and the co-pay for the appliance when you are fit with it.

TrueBlue only authorizes its patients to only come in for a set amount of time, or a set amount of appointments. They will usually give this information in the approval letter. It is very important to remember when appointments are authorized otherwise they will not pay anything towards those appointments. We try to track these date limitations, but it can be missed on occasion. It is always easy to call the insurance to ask if you are still authorized. We can also extend that authorization if needed. We will only perform this process after we have verified that further treatment is indicated. Sometimes this extended treatment authorization will need to be submitted by the referring doctor. We can help you with this information when the time comes.


United Health Care

Before Coming In:
We are considered an out-of-network provider.  There is usually not much that is required from United Health Care before coming in to our office. It is best to call them and find out if your policy will have any benefits for you towards this treatment.

Many times after the patient has come in for treatment and submitted claims we have found that UHC won’t always pay on claims that are submitted the first time. It usually takes a few submissions and to call and work with them and send in the same, complete information for them to pay as they said they would. Don’t give up on them, if you submit everything that they ask for, you will hopefully be reimbursed. It just takes endurance.


Patients involved in Accidents
Patients that are seen in our office and have been involved in an accident (motor vehicle accident) will still be responsible for the fees in our office at the time of check out of each appointment. And, as with most of our patients, the patient will need to submit to their insurance to receive reimbursement. Insurance reimbursement can take a long time (a couple of months up to two to five years or more) due to the actual parameters of the accident case the patient is involved in. If your symptoms are accident related, it is important to let us know, so that we can help you with reimbursement from your insurance.

Before Coming In:
We will need all of the accident information. This can be given over the phone.  We will need to know which insurance will be paying for this treatment and whether there is still medical pay (Med Pay) available and when it will exhaust.  We will also need to know the details of the case including the case number and adjuster, and all phone numbers and the address where the claims will be sent. Let your insurance also know when your appointment is and when the claims will be submitted so that they are aware of how the payment will work.