Insurance billing for oral orthotics

Provider

Medicare instructions on how to fill out a HCFA 1500
http://www.medicarenhic.com/
providers/billing/form1500guide_dec04.pd

 

What about Medicare and Federal Employee Contracts?

Medicare will pay only contracted providers; there is no Gap Exception available. Medicare has two separate contracted groups: physicians and other medical provider’s contract under the area of medical services, companies that actually sell medical goods, such as CPAP machines, wheelchairs and nebulizers, have a DME contract. Dentists can sign a medical contract, but they do not qualify for a DME contract. This means that dentists cannot even bill Medicare for an oral appliance used to treat obstructive sleep apnea.

Patients with Medicare coverage will need to apply to Medicare for reimbursement for the cost of any oral appliance fabricated - after paying the dentist out of pocket. Medicare has a very strict medical policy for coverage of oral appliance therapy.

  1. They have a different definition of obstructive sleep apnea and it is more stringent than commercial insurance companies.
  2. They require a prescription from the patient’s physician that orders the dentist to make an oral orthotic.
  3. The patient must have a sleep study done with the oral appliance in the mouth which proves that the oral orthotic is successful in controlling the patient’s obstructive sleep apnea. If the sleep study shows inadequate improvement, there will be no Medicare coverage.
  4. Medicare will reimburse the patient based on their fee schedule, not the dentist’s. Medicare may reimburse only 1/3 of the dentist’s fee.
  5. Expect Medicare to deny coverage the first time all of the paperwork is filed. Appealing their decision is standard operating procedure.
  6. Medicare form 0938-0008 (also known as a HCFA-1490S) must be obtained by the patient, fully filled out and sent in with all of the other documentation.
  7. Secondary insurers may, in rare instances, cover the cost of oral orthotic treatment at the same fees they allow for their primary subscribers. This is a very unusual occurrence.

Federal Blue Cross Blue Shield:

  1. Does not prior authorize DME coverage.
  2. Does not precertify payment for oral orthotics.
  3. May cover less than 0-50% of the costs.

Tricare: Dependents of the US Armed Forces:

  1. Will not pay anyone who is not a contracted provider.
  2. Requires the referring physician to obtain all of the appropriate referrals.
  3. Has minimal coverage for oral orthotics.

(Note: Members of the Armed Forces and the National Guard who are diagnosed with obstructive sleep apnea and treated with CPAP are considered “non-deployable” and may be released from the service. Oral orthotics and surgery may be the therapy of choice.)

Welfare / State Assistance:

I know of no dental provider who accepts this form of payment and is a Diplomate the Board of Dental Sleep Medicine. I would suggest that patients with this form of medical coverage assume all care is out-of-pocket. Some patienst have worked with their social workers and been reimbursed in part or wholly by State Aid.

Denist1

Dentists play an important role in the team approach to the treatment of obstructive sleep apnea.

Physicians, dentists, psychologists, and respiratory therapists all pool their knowledge to treat each patient appropriately and effectively.

Dentists who are specifically trained in aspects of sleep medicine and have a command of multiple appliance modalities are of great help to physicians in treating patients with sleep disordered breathing problems.

AVALABLE OFFICE HOURS:

9:00 t o 5:00 (Mon)
9:00 to 5:00 (Wed–Sat)
12:00 to5:00 (Sun)
CALL 617.964.4028
in Massachusetts
317.842.9866
in Indiana

 

The National Center on Sleep Disorders Research, can provide you with sleep education materials. As well as publications on heart, lung and blood research:
Two Rockledge Center, Suite 7024, 6701Rockledge Drive, MSC 7920, Betesda, MD 20892-7920
(P)301.435.0199 /
(F) 301.480.3451
www.nhlbi.nih.gov/about/ncsdr/

Information about sleep disorders may be obtained from NHLBI:
NHLBI Information Center
P. O. Box 30105, Bethesda, MD 20824-0105
(P) 301.251.1222 / (F) 301.251.122
www.nhlbi.nih.gov/