Insurance
Here at the Craniofacial Pain Center we care that our patients are able to understand and receive the best possible reimbursement from their insurance. This insurance section has been provided with many links to help each patient obtain the necessary skills for submitting to their insurance properly and to fully understand why we are not able to submit for them. We hope this information is helpful, easy to follow, and clear to use. We also wish you the best of luck in submitting.
Q. Do you accept my insurance?
A. Because Dr. Spencer is in the unique position of being a dentist treating TMJ, which is considered a medical condition, he is unable to contract with insurance companies for payment. He is therefore unable to accept insurance as they will not pay for many of the treatments we offer. We do however, assist our patients with submission to their insurance and find that they are able to receive better coverage and reimbursement when they submit individually.
Q. Will my insurance pay for this? Do I have benefits/coverage for TMJ treatment?
A. Each insurance policy is different. Many individual policies do have benefits regarding the treatment for TMJ/TMD. If your policy has an exclusion for the services provided in our office, your insurance will not cover your treatment. We suggest that you call your insurance or look through your benefits booklet. Some things to ask and look for:
In addition it is 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/provider that works in this specific field of interest and that there are no other providers in the area with this expertise. Lastly, 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 to reimburse or not.
Q. Do you submit my claims for insurance?
A. We ask that our patients submit their own claims as we are not able to submit claims to your insurance company. We help our patients with the submission process by providing the patient with the proper claim forms to submit to their insurance. If your individual policy has benefits for this treatment they will reimburse you, the patient, directly.
Q. Is Dr. Spencer a preferred provider for my insurance?
A. Because Dr. Spencer is a dentist he is not able to contract with medical insurance for the treatment of TMJ/TMD which is considered a medical condition, not dental.
The only insurance that we have a contract with is Medicare. Medicare patients will only pay the co-pay at each office visit, but may be responsible for payment in the case that Medicare doesn’t completely cover the procedure. (See Medicare under Individual Insurances Link).
Q. If Dr. Spencer is not a contracted provider, can I see him?
A. Some policies require you to initially use their “contracted or preferred providers”. However, it is possible to see someone outside of the network. Some insurances have an out-of-network rate which requires additional information to be submitted for this allowance. Check with your insurance carrier to see what their guidelines on out-of-network providers are.
It may be possible to receive an authorization for an out-of-network waiver. Craniofacial Pain Center is the only clinic in the area that works specifically with the treatment of TMJ/TMD. Because of this, we may be able to receive more reimbursement for our patients through an out-of-network waiver.
Q. Why do you ask for my insurance card and information if this office doesn’t submit?
A. We ask for a copy of your insurance card at check in and will input your insurance information into our system so that we can help you later with this complicated insurance process. Many times after the patient submits a claim, the insurance will ask for additional clinical notes and have questions for us. We use your insurance card for reference and to help quicken the process. Without this info we would not be able to submit the additional notes and diagnosis info when requested.
Q. Does insurance consider TMJ/TMD treatment as medical or dental?
A. The treatment for TMJ/TMD usually has better coverage when submitted as a medical procedure rather than a dental procedure. Even though the doctor is a dentist, the actual treatment is linked to a medical diagnosis and the medical insurance will usually have better coverage for these services.
When we print out claims for you at the end of your office visit we will always print them with medical codes for you to submit.
Q. Can these procedures be billed through my dental insurance?
A. If you have benefits for the treatment of TMJ/TMD, the medical portion of your policy usually provides much better reimbursement than your dental policy. However, if you have no medical benefits, it is easy for us to code the billing for dental submission.
If you find your dental insurance has coverage and you would like the insurance claims printed as dental codes, we can easily change the printout. You will just need to let the front receptionist know to change them.
Q. How do I submit claims to my insurance?
A. This will be fully described under the Claims Submission Link.
Q. What if I have a problem with submitting my claims?
A. We are happy to help you with any problems you might incur during the submission process. We will provide you with any documentation or letters to help with your reimbursement. Please let us know if you are experiencing trouble so that we may assist you.
Q. What all do I need to come in for an initial evaluation?
A. To set up an initial appointment you will need to call our office and reserve a time. It is very important for insurance purposes to have a doctor referral to come see us. Most insurance companies like to see that the patient has been referred by a regular dentist or physician. Some insurance companies require pre-authorizations for some procedures. (For more additional info on pre-authorizations see Before Coming In and Prior Authorization links).
We will provide paperwork to fill out right as you come in for your first appointment. The doctor will need to have a panoramic x-ray for his first evaluation. Many dentists will take a panoramic x-ray every couple of years. We are able to use these (or a copy) if it was taken in the last 6 months. We like to have it current as your mouth is constantly changing. We can also take one here at your first appointment if you don’t already have one.
It is also very important for insurance purposes to have a doctor referral to come see us. Most insurances like to see that the patient has been referred by a regular dentist or physician. Some insurances require prior-authorizations for some procedures. (For more additional info on pre-authorizations see Before Coming In and Prior Authorization links).
Q. How is TMJ treated? What is typical treatment for TMJ?
A. At our office we offer conservative, non-surgical treatment by gradually moving the jaw back to its correct position. The doctor is not an oral surgeon and our treatment methods do not include breaking the jaw or the use of surgery to correct TMJ. The majority of our patients come in for two initial appointments to be diagnosed. At these appointments the patient visits with the doctor to find out the exact cause and location of the pain and dysfunction. The doctor will perform a complete head and neck examination to find the best way to treat the patient.
If further treatment is indicated, oral appliances (splints) will be made in a lab for the patient to wear in the mouth. Usually this treatment is for the next 4 to 6 months. They can be needed on a more permanent basis if conditions require it. These appliances fit in the mouth (similar to retainers) and are worn as directed to move the jaw into the correct position and realign the bite. Our patients are usually fit with two splints at their third visit. One splint will be worn during the day (daysplint), while the other is worn only at night (nightguard). The patient will then typically return every few weeks for follow up and adjustment appointments after they have received the splints. These appointments allow for adjustment to the splint which will slowly correct the positioning of the jaw while reducing the symptoms.
Depending on the severity and symptoms, some of our patients will only receive one splint to treat the jaw. This treatment follows the same guidelines as patients that wear two splints. Most of our patients complete this therapy process within 6 months to a year.
Q. Why won’t my insurance cover treatment for “TMJ/TMD?”
A. Insurance companies make choices all the time regarding what they will or won’t cover. These decisions are usually financial in nature. Insurance coverage varies from state to state and from company to company.
“Temporomandibular Joint Dysfunction” is a non-specific diagnosis. Even when a specific diagnosis is made, such as tension type headache, capsulitis of the TM joint, disc displacement or even degenerative arthritis, many insurance companies will still deny coverage based on their “TMJ exclusion.”
The history behind this outdated principal dates back decades. “TMJ” became a common diagnosis in the 60’s and 70’s. It was not at all clear what caused these problems and treatments were unspecific and often very expensive. Since the disorder was considered more of a medical problem then a dental problem, medical insurance started to be billed by dentists for the diagnosis and treatment. In some cases dentists would recommend orthodontics or crowning of many of the teeth as treatment. These procedures were costly, and insurance companies did not feel that they were really medically necessary. Because of “a few bad apples,” insurance companies developed “TMJ exclusions” to protect their profits. BlueCross of Idaho continues to have a “TMJ exclusion” on virtually all of their polices (except for a few State and local government policies). This is very disappointing for the patient who has seen multiple practitioners for their pain, including ENT’s, neurologists, family doctors, physical therapists, pain doctors, etc.—all of whom were covered by their insurance, and then find out that treatment for the same pain problem is not covered in our office due to a TMJ exclusion. Dr. Spencer has had many discussions with BlueCross regarding their exclusion. They say that it is the company’s fault for choosing a plan with a TMJ/TMD exclusion.
Over the years some insurance companies have created a “TMJ benefit” which is usually a limited amount of coverage, similar to the coverage limits on physical therapy.
In 23 States patients and doctors have gone to their State legislature to mandate changes. In these 23 States laws have been passed that require insurance companies to cover the diagnosis and treatment of TMJ. The legislature has not yet done this in Idaho, but our office would certainly support any grass roots efforts by our patients. After all, you just want to receive the benefits that you pay for.
Q. What if you don’t diagnose my problem as “TMJ” and just use some other diagnosis code?
A. Most insurance companies don’t seem to care what your diagnosis actually is. Dr. Spencer often jokes with patients that “I could diagnose you with ingrown toenail and your insurance company will deny your claim saying that you have a TMJ exclusion.” Of course this is ridiculous, but it is closer to the truth than you might imagine. As mentioned above, even when a patient has been treated for years for a condition, (headache, for example) by multiple different care givers, all of whom have been covered by insurance, once the patient is referred to our office the headache diagnosis is re-interpreted as “TMJ” (even though no TMJ diagnosis is made). We believe this is because diagnosis and treatment of TMJ is virtually always performed by dental professionals—which makes it easy for the insurance company to pick these claims out.
Frequently Asked Questions
For the treatment of TMJ
For the treatment of TMJ
Q. Do you accept my insurance?
A. Because Dr. Spencer is in the unique position of being a dentist treating TMJ, which is considered a medical condition, he is unable to contract with insurance companies for payment. He is therefore unable to accept insurance as they will not pay for many of the treatments we offer. We do however, assist our patients with submission to their insurance and find that they are able to receive better coverage and reimbursement when they submit individually.
Q. Will my insurance pay for this? Do I have benefits/coverage for TMJ treatment?
A. Each insurance policy is different. Many individual policies do have benefits regarding the treatment for TMJ/TMD. If your policy has an exclusion for the services provided in our office, your insurance will not cover your treatment. We suggest that you call your insurance or look through your benefits booklet. Some things to ask and look for:
- Is there an exclusion for the treatment of TMJ/TMD and what would be covered as you come in for treatment.
- What is the amount of deductible you have left to pay.
- Find out which procedures and office visits would be covered and at what rate.
- Pleas make a note of the person you spoke with, what they told you and the day you called.
In addition it is 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/provider that works in this specific field of interest and that there are no other providers in the area with this expertise. Lastly, 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 to reimburse or not.
Q. Do you submit my claims for insurance?
A. We ask that our patients submit their own claims as we are not able to submit claims to your insurance company. We help our patients with the submission process by providing the patient with the proper claim forms to submit to their insurance. If your individual policy has benefits for this treatment they will reimburse you, the patient, directly.
Q. Is Dr. Spencer a preferred provider for my insurance?
A. Because Dr. Spencer is a dentist he is not able to contract with medical insurance for the treatment of TMJ/TMD which is considered a medical condition, not dental.
The only insurance that we have a contract with is Medicare. Medicare patients will only pay the co-pay at each office visit, but may be responsible for payment in the case that Medicare doesn’t completely cover the procedure. (See Medicare under Individual Insurances Link).
Q. If Dr. Spencer is not a contracted provider, can I see him?
A. Some policies require you to initially use their “contracted or preferred providers”. However, it is possible to see someone outside of the network. Some insurances have an out-of-network rate which requires additional information to be submitted for this allowance. Check with your insurance carrier to see what their guidelines on out-of-network providers are.
It may be possible to receive an authorization for an out-of-network waiver. Craniofacial Pain Center is the only clinic in the area that works specifically with the treatment of TMJ/TMD. Because of this, we may be able to receive more reimbursement for our patients through an out-of-network waiver.
Q. Why do you ask for my insurance card and information if this office doesn’t submit?
A. We ask for a copy of your insurance card at check in and will input your insurance information into our system so that we can help you later with this complicated insurance process. Many times after the patient submits a claim, the insurance will ask for additional clinical notes and have questions for us. We use your insurance card for reference and to help quicken the process. Without this info we would not be able to submit the additional notes and diagnosis info when requested.
Q. Does insurance consider TMJ/TMD treatment as medical or dental?
A. The treatment for TMJ/TMD usually has better coverage when submitted as a medical procedure rather than a dental procedure. Even though the doctor is a dentist, the actual treatment is linked to a medical diagnosis and the medical insurance will usually have better coverage for these services.
When we print out claims for you at the end of your office visit we will always print them with medical codes for you to submit.
Q. Can these procedures be billed through my dental insurance?
A. If you have benefits for the treatment of TMJ/TMD, the medical portion of your policy usually provides much better reimbursement than your dental policy. However, if you have no medical benefits, it is easy for us to code the billing for dental submission.
If you find your dental insurance has coverage and you would like the insurance claims printed as dental codes, we can easily change the printout. You will just need to let the front receptionist know to change them.
Q. How do I submit claims to my insurance?
A. This will be fully described under the Claims Submission Link.
Q. What if I have a problem with submitting my claims?
A. We are happy to help you with any problems you might incur during the submission process. We will provide you with any documentation or letters to help with your reimbursement. Please let us know if you are experiencing trouble so that we may assist you.
Q. What all do I need to come in for an initial evaluation?
A. To set up an initial appointment you will need to call our office and reserve a time. It is very important for insurance purposes to have a doctor referral to come see us. Most insurance companies like to see that the patient has been referred by a regular dentist or physician. Some insurance companies require pre-authorizations for some procedures. (For more additional info on pre-authorizations see Before Coming In and Prior Authorization links).
We will provide paperwork to fill out right as you come in for your first appointment. The doctor will need to have a panoramic x-ray for his first evaluation. Many dentists will take a panoramic x-ray every couple of years. We are able to use these (or a copy) if it was taken in the last 6 months. We like to have it current as your mouth is constantly changing. We can also take one here at your first appointment if you don’t already have one.
It is also very important for insurance purposes to have a doctor referral to come see us. Most insurances like to see that the patient has been referred by a regular dentist or physician. Some insurances require prior-authorizations for some procedures. (For more additional info on pre-authorizations see Before Coming In and Prior Authorization links).
Q. How is TMJ treated? What is typical treatment for TMJ?
A. At our office we offer conservative, non-surgical treatment by gradually moving the jaw back to its correct position. The doctor is not an oral surgeon and our treatment methods do not include breaking the jaw or the use of surgery to correct TMJ. The majority of our patients come in for two initial appointments to be diagnosed. At these appointments the patient visits with the doctor to find out the exact cause and location of the pain and dysfunction. The doctor will perform a complete head and neck examination to find the best way to treat the patient.
If further treatment is indicated, oral appliances (splints) will be made in a lab for the patient to wear in the mouth. Usually this treatment is for the next 4 to 6 months. They can be needed on a more permanent basis if conditions require it. These appliances fit in the mouth (similar to retainers) and are worn as directed to move the jaw into the correct position and realign the bite. Our patients are usually fit with two splints at their third visit. One splint will be worn during the day (daysplint), while the other is worn only at night (nightguard). The patient will then typically return every few weeks for follow up and adjustment appointments after they have received the splints. These appointments allow for adjustment to the splint which will slowly correct the positioning of the jaw while reducing the symptoms.
Depending on the severity and symptoms, some of our patients will only receive one splint to treat the jaw. This treatment follows the same guidelines as patients that wear two splints. Most of our patients complete this therapy process within 6 months to a year.
Q. Why won’t my insurance cover treatment for “TMJ/TMD?”
A. Insurance companies make choices all the time regarding what they will or won’t cover. These decisions are usually financial in nature. Insurance coverage varies from state to state and from company to company.
“Temporomandibular Joint Dysfunction” is a non-specific diagnosis. Even when a specific diagnosis is made, such as tension type headache, capsulitis of the TM joint, disc displacement or even degenerative arthritis, many insurance companies will still deny coverage based on their “TMJ exclusion.”
The history behind this outdated principal dates back decades. “TMJ” became a common diagnosis in the 60’s and 70’s. It was not at all clear what caused these problems and treatments were unspecific and often very expensive. Since the disorder was considered more of a medical problem then a dental problem, medical insurance started to be billed by dentists for the diagnosis and treatment. In some cases dentists would recommend orthodontics or crowning of many of the teeth as treatment. These procedures were costly, and insurance companies did not feel that they were really medically necessary. Because of “a few bad apples,” insurance companies developed “TMJ exclusions” to protect their profits. BlueCross of Idaho continues to have a “TMJ exclusion” on virtually all of their polices (except for a few State and local government policies). This is very disappointing for the patient who has seen multiple practitioners for their pain, including ENT’s, neurologists, family doctors, physical therapists, pain doctors, etc.—all of whom were covered by their insurance, and then find out that treatment for the same pain problem is not covered in our office due to a TMJ exclusion. Dr. Spencer has had many discussions with BlueCross regarding their exclusion. They say that it is the company’s fault for choosing a plan with a TMJ/TMD exclusion.
Over the years some insurance companies have created a “TMJ benefit” which is usually a limited amount of coverage, similar to the coverage limits on physical therapy.
In 23 States patients and doctors have gone to their State legislature to mandate changes. In these 23 States laws have been passed that require insurance companies to cover the diagnosis and treatment of TMJ. The legislature has not yet done this in Idaho, but our office would certainly support any grass roots efforts by our patients. After all, you just want to receive the benefits that you pay for.
Q. What if you don’t diagnose my problem as “TMJ” and just use some other diagnosis code?
A. Most insurance companies don’t seem to care what your diagnosis actually is. Dr. Spencer often jokes with patients that “I could diagnose you with ingrown toenail and your insurance company will deny your claim saying that you have a TMJ exclusion.” Of course this is ridiculous, but it is closer to the truth than you might imagine. As mentioned above, even when a patient has been treated for years for a condition, (headache, for example) by multiple different care givers, all of whom have been covered by insurance, once the patient is referred to our office the headache diagnosis is re-interpreted as “TMJ” (even though no TMJ diagnosis is made). We believe this is because diagnosis and treatment of TMJ is virtually always performed by dental professionals—which makes it easy for the insurance company to pick these claims out.