Preparing to File Medical Insurance in a Dental Office

As dental and medical care continue to integrate, it’s becoming more common to file medical insurance claims in a dental office. Here are some tips to help you along the way.

Medical insurance info

Obtain the patient’s medical insurance information when you obtain the dental insurance information.  Your current updated software system may have this on the patient registration form.  Take a copy of the cards front and back.  Emphasize in writing that while some procedures may be filed with the patient’s medical plan, the patient is responsible for the entire fee.

Contact the medical carrier

Contact the medical carrier prior to treatment to determine eligibility, benefits, and the type of medical plan you are billing. HMOs or PPOs may decline benefits, pay the subscriber, or pay a lower percentage to non-participating providers.  Find out the medical plan’s special requirements for filing dental procedures with medical as primary. A subscriber has the right to file with the medical as primary as long as it is not written in their plan that dental must be filed first if the procedure is performed by a dentist.

Trauma claims

Trauma claims require special handling. It is a good idea to request that trauma patients provide you with a copy of the emergency room report or the police report if either applies. These should be attached to the claim along with the narrative. Also, liability carriers (e.g. homeowners insurance, automobile insurance, etc.) will typically be primary to medical carriers.

CPT Codes

Medical procedure codes are called CPT Codes. Similar to the dental procedure (CDT) codes, they are divided into categories. These categories are evaluation and management; anesthesia; surgery; radiology; pathology and laboratory; and medicine. The evaluation and management codes are not like the dental exam codes.  Dental practices should cautiously choose codes from this section as most mid-level to high-level codes require a time factor and the evaluation of multiple body systems.  Part of the difficulty in cross-coding is that very few CPT codes parallel CDT codes. Some insurance carriers will accept CDT codes on the medical claim form.

Within the CPT code set is a subset of codes called modifiers which indicate specific details about certain procedures. Examples include a procedure that is less involved than the code normally used, or more than one type of procedure was performed on the same date by the same provider. Modifiers would also be used to explain that an exam and x-ray were performed on the same date of service and should be paid as separate entities. There are many more modifiers and it is important to know when and how to use them.

Dental record

The dental record must be complete and legible.  All entries are dated and signed. Each patient appointment must include the date, the reason for the encounter, appropriate history and physical/oral exam, a review of the lab, radiograph data and other ancillary services (where appropriate), an assessment, and a treatment plan or release plan.  Past and present diagnoses should be accessible to the treating or consulting healthcare professional. The reason for and results of radiographs, tests, and other services should be documented in the dental record. Also include patient progress reports such as response to treatment, change in treatment or diagnoses, and a treatment plan.

If you are struggling with preparing medical claims consider partnering with eAssist. Our oral surgery billing team is familiar with all aspects of medical claims and will be happy to assist you. To learn more schedule a consultation.

Sandy Odle

Co-Founder and CXO, eAssist

Sandy Odle is the Co-Founder and CXO of eAssist Dental Solutions, where she has played a key role in shaping the company’s business and marketing strategies, leading to record growth and national recognition on the Inc. 500 and Utah Top 100 lists. A passionate social entrepreneur, Sandy believes that business is about building meaningful connections and creating personalized solutions that truly meet customer needs. Her relentless commitment to delivering exceptional client experiences is at the heart of eAssist’s mission. Drawing on the discipline and attention to detail honed during her early career as a ballet dancer, Sandy brings a unique blend of creativity, precision, and work ethic to everything she does.