At The Pain and Sleep Therapy Center(s), we want to ensure that your experience with insurance matters is as caring and helpful as possible. While we’re not participating providers with medical or dental insurance companies, we are committed to assisting you throughout the insurance process. As a courtesy, we are more than happy to submit any necessary insurance forms or documentation to facilitate the smooth processing of claims.
Typically, treatments related to TMJ and sleep breathing are filed with medical insurance. However, it’s important to note that some dental plans may offer limited coverage for TMJ – please check with your dental carrier for specifics. Understanding the details of your plan and its payment allowances is crucial, and we are here to help you navigate this information.
Once The Pain and Sleep Therapy Center has developed a diagnosis and treatment plan tailored to your needs, we will promptly submit the relevant information to your insurance company to assist with any required authorizations. It’s essential to be aware that no insurance plan covers all costs, and we want you to feel informed about your coverage.
While we aim to obtain as much information as possible from the insurance company, it’s worth noting that they may have limitations on the information they provide us. Since we are considered an out-of-network provider, your insurance company may only share basic plan benefits with our office. Remember, insurance contracts are agreements between you, the member, your employer, and the insurance carrier.
To make well-informed decisions about your payment arrangements, we recommend reaching out to your insurance carrier directly to obtain specific benefit information. Our team is here to support you every step of the way, and we encourage you to contact us with any questions or concerns.
The Pain and Sleep Therapy Center is not a participating provider with medical or dental insurance companies. As a courtesy, we would be happy to file any necessary insurance forms or documentation to assist the processing of claims. Typically, TMJ and/or sleep breathing treatments are filed with medical insurance, however; some dental plans have limited coverage for TMJ – be sure to check with your dental carrier. We feel it is important for you to understand your plan and its payment allowances.
Once The Pain and Sleep Therapy Center has developed a diagnosis and treatment plan for you, we will send the appropriate information to your insurance company to assist with required authorizations. Please keep in mind no insurance plan covers all costs.
Most have member service representatives available to assist in understanding your plan’s specific benefits. Since The Pain and Sleep Therapy Center is an out of network provider, your insurance company may be unwilling to provide any other information than the basic plan benefits to our office. Insurance contracts are between you the member, employer and the insurance carrier.
In-network or participating provider: The healthcare professional has a contract with your insurance company agreeing to a dollar amount for a service and adjusts the fee based on the contracted amount.
Out-of-network or non-contracted provider: The healthcare professional does not have a contract for services with the insurance company. There may be benefits available, however; the benefit is not determined until the claim is reviewed. Therefore, the insurance company is not able to provide the dollar amount for a service to an out of network provider.
HMO (Health Maintenance Organization) vs. PPO (Preferred Provider Organization) plans: With an HMO, you have benefits available only when you received services from an in-network or contracted provider. PPO plans allow benefits for both in and out-of-network providers. Occasionally, if receiving a service from an out-of-network provider or facility the benefit may be reduced but, there is still coverage of some dollar amount.
Deductible: The dollar amount that must be satisfied prior to the insurance plan making payment or reimbursement.
Co-Insurance: The percentage the member is responsible for covering after the deductible is met.
Reasonable and customary limits or allowed amounts for services: The arbitrary amount an insurance company sets as the fee for a particular product, procedure, or service. (For example: We will bill them the full fee for each service, your benefit or coverage/ payment will be based on the dollar amount they have chosen.)
Exclusions and limitations: There are times where an insurance plan or group will not provide any payment or allow any benefit for a particular diagnosis or service. Limitations are occasionally seen as a maximum amount an insurance company will allow or pay for a particular diagnosis or service. The limit can be either in the form of a dollar amount or percentage.
CPT (Current Procedural Terminology) code: The code or number that represents the service, procedure, or equipment being performed or provided on the claim form.
ICD 10 (International Classification of Diseases) – Diagnosis code: The code or number that represents why the service, procedure or equipment was done or provided.