Question

Q: Are dental implants covered by medical plans?

A: Implant coverage is plan specific. Some medical plans allow reimbursement for dental implants when
provided in cases for reconstruction following trauma. Many medical plans specifically exclude dental implant coverage. Contact the patient’s medical plan to verify benefits and coverage prior to initiating treatment.

Q: Which dental procedures are covered by medical payers?

A: Medical coverage for any procedure is plan specific. However, some services provided by dentists are typically considered medical in nature and are covered by most medical payers. Common procedures covered by medical payers include, but are not limited to:

  • Treatment required due to an accidental injury (including dental restorations)
  • Biopsies
  • Cancer related treatment
  • Oral appliances for the treatment of obstructive sleep apnea
  • Frenectomy for newborns with feeding problems
  • Treatment required to correct congenital malformations
  • Evaluation and some treatment for temporomandibular joint disorders (TMD/TMJ)

Q: Do medical payers provide reimbursement for dental procedures?

A: Medical coverage for dental procedures is plan specific. Some medical plans do provide limited benefits
for dental procedures. However, medical plans often have high deductibles and out-of-network limitations,
which decrease the actual dollar amount of reimbursement available.

Q: Can I submit CDT (dental codes) on a medical claim form?

A: Some medical payers do allow dental codes to be reported on the medical claim form, CMS 1500 (2-12). Coding guidelines state that the code most accurately describing the procedure or service provided should be reported. In many instances, this would be the CDT code. Some medical payers that do accept dental codes require that only 1 type of procedure code be reported on the claim form (i.e., per each claim form, report only CDT codes or only CPT/HCPCS codes).

Q: What is a HCPCS code?

A: The Healthcare Common Procedure Coding System (HCPCS, commonly referred as the acronym “hick picks”) is a set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT). HCPCS codes are Level II codes and are primarily used to report medical services, equipment (e.g., an obstructive sleep apnea appliance), and supplies on the medical claim form. HCPCS codes are maintained by Centers for Medicaid and Medicare Services (CMS).

Q: How does a “gap exception” work?

A: Some payers may consider the provider as in-network when a gap exception is granted. Some payers may pay your full fee, while others only reimburse the allowable fee. Consider asking if the procedure can be considered for additional in-network benefits when there is no in-network provider. Not all payers have a gap exception provision; so ask the payer before requesting a gap exception.

Sometimes, if no other provider is available, the payer may allow the practice to collect its full fee, whether by the plan paying 100% or the patient is balance billed. If there is an in-network provider, the payer may grant the gap exception but only allow the provider to collect up to the network fee.

Note: Some payers require the provider to accept the in-network fee as payment in full.

Q: Where can I obtain a medical claim form?

A: First, check with your practice management software vendor. Often, a medical claim can be generated directly from your dental software. The CMS 1500 (02-12) Medical Claim Forms are also available at office supply
stores and in small quantities in our online store at https://practicebooster.com/store.asp. Additionally,
software designed specifically to allow the completion and printing of medial claims is available through
several companies. Two sources we recommend are https://fiachraforms.com/ and https://ub04software.
com/.