(This is not intended to be a full/comprehensive guide to Insurance and the process of filing claims)
The professional fees for your anesthesiologist’s services are separate from your dental bill. Our services are available by request through the offices of dental providers. CarePoint Anesthesia’s Doctors are not currently providers with any private insurance company and cannot usually accept insurance assignment, BUT your medical/dental insurance may reimburse you directly for all or part of the anesthesia fee.
You are the customer in this situation and your insurance company will be more responsive to your direct claims. We will gladly help patients who have health/dental insurance receive the maximum benefits provided by your insurance company. If your dental insurance does not cover anesthesia services for certain dental procedures you may also attempt to have these services covered by your medical insurance policy. The process for verification, pre-authorization and submission for reimbursement are similar for both.
Due to office-based anesthesia’s (OBA) recent introduction within the medical and dental community, many health/dental plans have not formally completed their review of this mode of care or you may find that your specific health/dental plan may not currently consider office-based anesthesia (OBA) for pediatric patients/adults as a covered benefit for treatment of dental conditions. As more parents/patients, such as you, request coverage for OBA for children’s dental treatment or your own treatment, the reimbursement process will get easier and more health/dental plans may cover this in the future.
This guide provides details on how to find out if your health/dental plan covers office- based anesthesia (OBA) for dental procedures and for obtaining pre-authorization approval for treatment. It overviews the steps you can follow if you have individual health/dental insurance or group health insurance through your employer.
Step 1. Are you or your child a candidate for office-based anesthesia for dental care?
Step 2. Is office-based anesthesia a covered benefit under your health plan?
Step 3. Requesting pre-authorization for office-based anesthesia dental treatment.
Step 4. Obtaining the decision
Step 5. Appealing a denial
Step 1: Are you or your child a candidate for office-based anesthesia (OBA) for dental care?
Contact your physician, pediatrician, dentist, or the office-based anesthesiologist to begin the prescreening process to determine if you or your child is a candidate for OBA for dental treatment.
Once you have completed the required evaluation process and it is determined that you or your child is a candidate for OBA for dental treatment, call your insurance company (Step 2) to determine your or your child’s eligibility for OBA benefits.
Step 2: Is office-based anesthesia (OBA) a covered benefit under your health plan?
Contact your health/dental plan by phone or in writing to ascertain if OBA for dental treatment is a covered benefit under your plan. Provide them with the following OBA for dental patients Current Procedural Terminology (CPT) procedure codes:
Medical Insurance CPT Codes:
00170 Anesthesia for Intraoral Procedures
Dental Insurance CDT Codes:
D9219 Evaluation for Deep Sedation or General Anesthesia
D9223 Deep Sedation/General Anesthesia
Plans determine this by reference to the codes used to bill for the treatment in question. If they tell you it is an approved procedure under your covered benefits, ask them to provide you with the details and the steps you need to complete in order to obtain pre- authorization of OBA for dental treatment.
If OBA for dental treatment is not a covered benefit, ask why it is not currently considered a covered service. They may answer that it is not considered a “medically necessary” procedure for the dental treatment, or it is not considered a covered benefit under your specific plan. Ask them what information and documentation you need to submit to get them to reconsider their decision to deny this service. They may ask for a Statement of Medical Necessity Form which your physician, pediatrician, anesthesia provider and/or dentist can help you fill out.
Record all contact information (including the person you are talking with and any person they recommend you contact) and what is discussed on the phone conversation.
Step 3: Requesting pre-authorization for office-based anesthesia for dental treatment.
When reviewing the plan details of your family’s health/dental policy, you may find mention of penalties or non-payment of claims for certain procedures that require pre- authorization. Not obtaining this pre-authorization for medical/dental services needed for any family member can dramatically increase your out-of-pocket costs. Your plan details should clearly outline all procedures that require pre-authorization. However, it is always a good idea to contact your insurance company in advance of any scheduled medical/dental procedure to verify that pre-authorization has been given. Ask for the claims number associated with this pre-authorization and, if possible, request a faxed copy for your records.
Remember Pre-authorization does not guarantee payment of benefits.
The pre-authorization request should include the following detailed information about your medical condition and your need to undergo OBA for dental treatment, all of which should be furnished by your physician/pediatrician and dentist (a sample medical necessity form can be found at carepointanesthesia.com (Statement of Medical Necessity Form)
Your physician, pediatrician or dentist may ask the health plan to call him or her with any questions about the letter or the need for office-based anesthesia for dental treatment. You may need letters from your physician, pediatrician, dentist and/or the anesthesiologist from the OBA practice that will be performing the OBA for you or your child’s dental treatment, outlining.
- You or your child’s medical condition with your child’s exact diagnosis and the symptoms associated with your child’s condition.
- The medical necessity for you or your child to undergo the dental procedure and the need for office-based anesthesia during this procedure.
- What health/dental problems could occur if you do not get office-based anesthesia for your child’s dental treatment?
- What other treatments or services you have already had for your child’s dental treatment, if any, and why these other alternative treatments did not allow you or your child’s dental treatment to precede.
Step 4: Obtaining the decision after Submitting Request for Pre-Authorization
Contact the health/dental plan claims office if you don’t receive a reply within two weeks and ask when a decision can be expected. (Many states require insurance companies to respond within 30 days).
Record the date of inquiry and the person with whom you spoke. Be patient and offer to provide any needed information. Your health/dental plan should provide a clinical reason for their decision, whether they approve or deny the request.
Your health/dental plan may deny office-based anesthesia for dental treatment, because
- This dental procedure is not considered “medically necessary”
- Your child is consider too old
- They do not offer this service under your health/dental plan to any plan participants and office-based anesthesia for dental treatment is not a “covered benefit” under your plan.
Whatever the reason for the denial, you have the right to appeal this, and should request details on these steps.
Step 5: Appealing a denial
If you are denied, this is their first response, not necessarily the last. Request a written response, detailing the reasons for denial. You will then have something specific to answer. The type of insurance you have determines whether state or federal law applies to the appeal process. If your plan is self-funded, then ERISA (federal law) applies and the Department of Labor has jurisdiction. If it is commercial insurance, state law applies and the state Division of Insurance (DOI) has jurisdiction.
A. Reconsideration of Denial (grievance letter)
If your health/dental plan denies your request for treatment, you should request an informal reconsideration (grievance appeal). You can do this by calling, writing or faxing the health/dental plan.
Contact your health/dental plan and have them provide you with the appropriate guidelines for your appeal. It is better to ask for your reconsideration in the form of a letter, so your request does not get lost. If you make your request by phone, record the date and who took your request. Health/dental plans should send you a letter stating that they received your request for informal reconsideration within 5 days.
In your letter, you should tell the health/dental plan the reasons why you disagree with their denial. If the reason for denial is that the service is not considered “medically necessary”, ask your physician, pediatrician and/or dentists to write a letter of medical necessity. Include in this letter, medical records, and documentation that supports your position for coverage in your informal reconsideration letter.
If the service is denied because it is “investigational”, this objection can be refuted by citing experience with thousands of office-base anesthetics for dental patients nationwide.
B. Written Appeal
If your health/dental plan denies office-based anesthesia services after an informal reconsideration, you should send a written letter to appeal their decision. You may ask your physician, pediatrician and/or dentist to help write the response.
Check with your health/dental plan for specific instructions and how long the appeal process takes. It is very important to submit your appeal as soon as you hear from your health/dental plan that they have denied your informal reconsideration.
Your appeal letter should directly address the reason for the denial of office-based anesthesia for dental treatment. In the letter, include any additional information not included in your informal reconsideration letter. If you did not submit a letter of medical necessity with your informal reconsideration, request your physician, pediatrician and/or dentist to write a letter of medical necessity. (See: Letters of Medical Necessity under Step 3).
Send the appeal to the claims manager (or the specified contact). Call to make sure it was received.
C. Second Appeal
If the first appeal is denied, ask again for the denial in writing. Also, inquire if another appeal is possible, to a higher-level person or committee. Should you be denied a second time, do not give up. Answer, or ask your physician, pediatrician and or dentist to answer, all objections and resubmit. Be patient and persistent as many claims have been authorized after two or more appeals.
D. Higher Level of Appeal – External Independent Review
You must check with your health/dental plan to see if you have the right to request an external independent review of their decision to deny coverage of office-based anesthesia for dental treatment. Your health/dental plan or employer can explain to you whether your type of insurance allows for an external review and the steps to take after your appeal is denied. An external independent review requires that someone, who is not employed by the insurance plan, review your request for office-based anesthesia (OBA) for dental treatment and make a decision independent of the health/dental plan. You must request this independent review within a certain amount of time after the health/dental plan denies your appeal. Your request for this review should be mailed directly to your health/dental plan. Your health/dental plan will send your request for an independent review, along with all of your information, to your State’s Department of Insurance. There is no charge to you for the external independent review.
For questions of medical necessity, the independent physician who reviews your case has 21 days to contact the Department of Insurance of his or her decision. The Department of Insurance will send you the decision 5 days following receipt of the decision. For questions of coverage, the Department of Insurance will mail you a decision within 15 days of receipt of the independent physician’s review. The external independent review decision is legally binding on your health/dental plan and you. On questions of medical necessity, if you disagree with the independent review, you may have the right to go to court to further your appeal. On questions of coverage, you or the insurance plan can ask for fair hearing. Information sent with the independent review decision will explain the process for requesting a fair hearing.
Is the appeal process different if denial was based on decisions of medical necessity versus questions of coverage?
Yes, the appeals process will differ depending why your case was denied. The review process used will depend on whether your case is based on the question of whether office-based anesthesia for dental treatment is medically necessary or whether it is a question of coverage.
A question of medical necessity means that the health/dental plan does not believe that office-based anesthesia for dental treatment is necessary to treat your or your child’s dental condition. In this case, a physician familiar with treating dental disease will review all the information you have submitted during the appeals process and determine if office-based anesthesia for you or your child is the most appropriate treatment choice for your specific case.
A question of coverage means the health/dental plan believes that office-based anesthesia (OBA) for dental treatment is not a covered benefit under the terms of your health insurance policy. An employee of your State Department of Insurance reviews questions of coverage. For all independent reviews, it is very important that they write all the reasons why the denial of office-based anesthesia for dental treatment is the wrong decision for your medical condition. Letters of medical necessity, your medical records, and OBA for dental treatment support documents from your treating dentist, physician, pediatrician and the anesthesiologist from the office-based anesthesia practice are critical for the independent physician to review. Once the external independent review is in process, contact your State Department of Insurance directly to make sure they have all your information.
For ERISA Complaints: If you are employed by an employer group who is self-insured and does not buy insurance from an insurance company and is self-funded (meaning that they provide their own insurance and bear their own risk), your employer must follow a federal law, the Employee Retirement Income Security Act, known as ERISA. If your employer has self-insured health insurance, you cannot ask for an external independent review through the State Department of Insurance. Under ERISA, if your appeal was denied, you may be entitled to file a complaint with the U. S. Department of Justice. You can contact them at 1-666-444-3272 or visit their website at www.dol.gov/ebsa for information on how to file a complaint.
Frequently Asked Questions
1. What is Office Based Anesthesia (OBA)?
Anesthesia provided in an office setting is a safe alternative to hospitals and ambulatory surgical centers (ASCs). It usually offers a more affordable, convenient and efficient option that is available in the familiar surroundings of your or your child’s dental office.
2. Will my insurance company or health/dental plan pay for OBA for myself or my child?
Payment and coverage of office-based anesthesia for dental patients will vary from plan to plan. Office-based anesthesia for adult and for pediatric dental patients is relatively new for the treatment of dental disease. Because this treatment option is relatively new, few insurance companies reimburse for this as part of their routine treatment options. It will be necessary for you to contact your health/dental plan to verify whether it is a covered benefit under your plan policy. At this time, payment for office-based anesthesia may be based on individual payer discretion and coverage may be determined on a case-by-case basis.
3. Do I need to get pre-authorization before treatment?
You should contact your health/dental plan to verify if pre-authorization of office-based anesthesia for dental treatment is necessary prior to scheduling your or your child’s dental treatment. We suggest you work with your referring physician, pediatrician, OBA providers and/or staff at the dentist’s office you have been referred to for treatment.
Prior to contacting your health/dental plan, we recommend your referring dentist, physician, OBA provider and/or pediatrician document the reason office-based anesthesia for dental treatment is the most appropriate treatment for your specific case. Your referring physician, pediatrician, OBA provider dentist, will need to provide you with documentation that supports medical necessity for treatment of you or your child’s dental condition and their choice of office-based anesthesia as the best treatment option.
4. What if I need office-based anesthesia immediately and my health/dental plan denies my request?
If your health/dental plan denies office-based anesthesia and it is determined that you need this treatment immediately, you can request an Expedited Medical/Dental Review. The purpose of an Expedited Medical/Dental Review is to require the health/dental plan to make a quick decision because your or your child’s health is at risk. Your referring dentist, physician or pediatrician must certify in writing that delaying this service could cause a significant negative change in your medical/dental condition.
The health plan should not question your dentists or physician’s certification and it should make a decision 1 business day after receiving the certification and other supporting information. If the health plan still denies OBA for you or your child, you can appeal and ask for an external independent review. The time allowed for the health/dental plan to respond to this type of request is very short. Contact your State Department of Insurance and request information on Expedited Medical/Dental Reviews.
5. What should I do if my health/dental plan denies my request for office-based anesthesia for dental treatment in the pre-authorization process?
For office-based anesthesia to be approved by your health/dental plan through the pre- authorization process, 3 conditions must be met:
(a) They must agree that treatment is necessary for your condition,
(b) They must agree office-based anesthesia is an appropriate treatment for your condition,
(c) They must agree to reimburse for this treatment.
If you complete the pre-authorization process and your plan does not consider OBA for dental treatment a covered benefit (or medically necessary) and denies your initial request for treatment, you are entitled to initiate a general grievance review of their denial decision. You must contact your health/dental plan to outline the protocol for the grievance process. You will need to follow the guidelines established by your health/dental plan. You may also be entitled to a second more formal independent review process if your health/dental plan denies treatment under the grievance process. You must exhaust the grievance process before attempting to initiate the independent review process.
6. What are the reasons why a health/dental plan will refuse to cover OBA for dental treatment?
A health/dental plan will base their denial on a combination of three different rulings. The plan may rule that office-based anesthesia for pediatric patients is a “non-covered service” for its eligible members; it is “not medically-necessary” for the treatment of dental disease or for a patient specific case; or from an insurance company perspective, they consider this an “experimental or investigational” treatment.
Your right to an external independent review will be dependent on the reason cited for the denial and your health/dental plan’s eligibility criteria for an independent review of a denial made through the grievance process.
7. Do I need to write a letter of appeal and forward it to my health/dental plan?
For both the grievance and the independent review process, you are typically required to formally appeal their denial decision in writing. Prior to writing your appeal letter, go to the Web page for your health/dental plan, or contact them directly for specific instructions on what written documentation is required to support your request for a review if their decision is to deny approval. Work with your referring physician, pediatrician and dentist and their staff to provide the appropriate documents you will need to start the appeals process. In addition to a letter of appeal, health/dental plans require additional supporting documents including a letter from your referring physician, pediatrician, and/or dentist recommending office-based anesthesia for you or your child and the reasons why office-based anesthesia should be a covered benefit for your specific case. Additionally, other support documents that are needed might include:
- Peer reviewed literature that demonstrates clinical efficacy and cost- effectiveness, medical literature and second opinions supporting medical necessity, copies of all information provided to the health/dental plan during the appeals process, and all documentation received from the health/dental plan during the appeals process documenting the reason for the denial.
8. What happens if I exhaust all levels of appeal?
Once you feel you have exhausted all avenues of appeal, you may want to consider other options for office-based anesthesia for you or your child’s dental treatment. Under some health plans, there are legal remedies available under state, federal, or ERISA regulations. For those who seek treatment outside of continued appeals or legal remedy, patient self-pay options may be a viable consideration. The majority of OBA practices providers offer Self-Pay programs for patients desiring treatment. Please contact your referring dentist, physician, pediatrician or your OBA anesthesiologist to discuss any financing options and alternative payment programs that might be available.
9. Do I have any other choices?
Yes. Because for some patients the need for treatment is urgent, or the patient feels this is the treatment method of choice, many decide to move forward with the treatment and pay for the procedure out of pocket. You must first contact your health/dental plan and get a formal denial of pre-authorization of OBA for you or your child’s dental treatment. Once you have this denial, you do have the right to appeal their non-coverage decision and denial of payment and request, either through your employer or insurance plan to be reimbursed for the expense.
Suggestions for contacting your health/dental plan:
- Always contact them in writing. Phone calls can be made, but written communication is more powerful.
- Be sure to follow-up all written communications with a phone call to make sure they received your letters.
- Keep a copy of all your letters for your records. Record all phone calls in a phone log.
- Keep a log of when, where, and to whom you sent your request.
- Send important documents by certified mail (return receipt), Federal Express, or
by fax with a confirmation sheet.
Know the Details of Your Health/Dental Insurance Policy
When you are shopping for family health/dental insurance, the plan details that are available to you are just an overview of the details of the policy. You are provided with a summary of benefits, but not all of the details of the policy. This may be available to you upon request, but is typically not provided until you have been approved for coverage and become a plan member. For group health/dental insurance, the insurance company will send you the plan details once you have enrolled in the group plan. The plan details, also referred to as “evidence of coverage,” is a booklet that provides you with all of the details about the plan in which you are enrolled. This will include a list of all the medical/dental benefits that are covered under your family plan, but in much greater detail than a standard benefit summary.