Hi all of my wonderful TMJoiners! Thank you for taking the time to visit my website and read this Blog! If you’re reading this, you likely watched my YouTube video about calling your medical insurance. The printable guide is linked as an image at the bottom of the post. I’d highly recommend saving it, printing it, and having it in front of you when you call your insurance company!
I want to be sure to clarify that this is a general guide. Things change with insurance companies rapidly, so this information may be outdated soon. Please also keep in mind that nothing your insurance company tells you over the phone is a guarantee of payment.
At my office, we are Out of Network with every major medical insurance. The reason for this is that TMJ is very rarely covered by any medical insurance, so there really is no network for TMJ coverage.
Here’s a summary of the information in the video:
- Be sure to get your representative’s name and write it down! Ask:
- Do I have Out of Network coverage?
- If you are told you DO NOT have Out of Network coverage, stop the call and get a reference number for the phone call for your records.
- If you are told yes, you DO have Out of Network coverage, then ask what your deductible is – both individual AND family. Then ask:
- Once the deductible is met, how much MAY the plan pay up to?
- What is my out of pocket cost for my medical insurance, individual and family, and how much have I met for this year?
- When does my insurance reset or restart?
Once you have all the answers to those questions and you’ve written them down, you can start asking more specific questions.
The first question we have is:
Is non surgical TMJ treatment included or excluded within your out of network coverage or plan?
If you’re told it’s excluded, you can get a call reference number and stop the call right there.
If you’re told it’s included, ask these follow up questions;
- Does my plan have limitations for non surgical TMJ treatment?
- Does my plan have specific exclusions for non-surgical TMJ treatment?
- Is there a lifetime maximum for non surgical TMJ treatment?
- Do I need a prior authorization for using these benefits?
If the person on the phone tells you you have exclusions for: oral appliances, splint therapy, orthotics, myofascial release, craniosacral therapy, or osteopathic manual therapy then the treatment at my office will NOT be covered by your insurance company and you would pay out of pocket for treatment.
This is very important: at the end of your phone call, be sure to get and write down the call reference number. That way if you call back later, then you can reference this specific conversation with all the questions you asked and the answers you received and you can try to hold your insurance company accountable for what you were told over the phone.
Keep in mind that this is just general information – none of this is set in stone. Every year, plans change and insurance companies add and remove coverage. And again, everything that you’re told over the phone is not a guarantee of payment.
Additionally, the way insurance works is this: a claim must be processed by the claims department. After it is processed, then the claims department will send you an Explanation of Benefits, also known as an EOB. So basically, there’s no way to know FOR SURE that your insurance will pay until you’ve already started treatment and a claim has been sent out. This seems ridiculous to me but this is how the system works and I have no control over it.
This is why at my office, we remove ourselves as the middle man between insurance companies and our valued patients. Instead, we provide our patients with a SuperBill. We are happy to set our patients up with specific and individualized financial agreements to make treatment accessible and affordable.
I hope you all find this information helpful! 🙂 And again – You can never have TMI about TMJ!
