Sleep Services

Please take a look through these commonly asked questions. If you have a question that is not answered here, free to contact us.

• Do you automatically submit claims for office visits?

We will only submit claims for office visits if a super bill is received.  Fill out a super bill for each patient and each visit.  Please select the appropriate office visit code and diagnosis, as well as providing the patient’s information and date of service.

• What fees do you charge?

We will charge any fee that you would like us to.  Write in your fee in the blank box next to the procedure code on the super bill.  We do have a list of codes and the associated fees that are commonly billed, but you should determine your own fees.

• What do I need to submit with each super bill?

You are required to submit a copy of the chart note/procedure with every super bill.  This will be used to document proof of service and medical necessity with the insurance carrier.

• Can I submit claims prior to rendering services?

Unlike Dental Insurance, Medical claims must be submitted after the service has been rendered.  Oral appliances are billed on the day that the appliance is seated in the patient’s mouth.  Submitting claims prior to rendering services is considered fraudulent and will result in the termination of your contract.

• What if my patient has Medicare?

Unfortunately, we cannot submit any claims to Medicare on your behalf unless you become a Medicare provider and a Medicare DME provider. We strongly discourage our clients from becoming Medicare providers due to the amount of work that it takes, the low reimbursement, and the difficulty in documenting and getting claims paid.  However, you can offer services to your Medicare patients on a  self pay, fee for service basis.  Make sure to have your patients fill out and sign a Medicare ABN (Advanced Beneficiary Notice).

• What if my patient has an HMO or EPO policy?

If there is no in-network dentist within a certain radius of the patient (most commonly 30 miles), we are sometimes able to receive a gap waiver or network exception.  However, the patient will need to get involved.  For HMO patients, refer them to their primary care physician.  Their primary care physician will have to authorize the oral appliance on your behalf and then we can submit the claim upon receipt of your super bill.  For EPO patients, the patient can request a gap waiver or network exception form from their insurance prior to receiving services.  If a gap waiver is not obtained ahead of time, we can appeal the claim after services are rendered.  Your office also has the ability to offer a private pay to these patients.

• How does a patient qualify for an oral appliance?

Every insurance carrier has their own medical policy in regards to obstructive sleep apnea.  However, in general, the patient must be diagnosed with obstructive sleep apnea by a sleep study, have considered/tried/failed PAP therapy, and have a prescription for an oral appliance.  Aetna’s medical policy is the best example for your office to follow.  You can view Aetna’s medical policy at http://www.aetna.com/cpb/medical/data/1_99/0004.html.  Section VII, C discusses oral appliances.

• Does my patient have to try CPAP first?

Every insurance carrier has their own medical policy in regards to obstructive sleep apnea.  BlueCross BlueShield of Illinois’s medical policy states it best:  “Oral appliances may be considered medically necessary…when conservative medical treatment options have been tried and failed (i.e., weight loss counseling, medications, avoidance of supine sleeping position).”  Most insurance carriers need a reason why the patient is electing an oral appliance over PAP therapy.   You can put this information in the patient’s chart notes or use the CPAP Intolerance Affidavit.

• How do we get the patient’s benefits for the oral appliance?

Our office will automatically verify benefits for the oral appliance with every home sleep study.  Once the patient has completed the sleep study, your office will receive both a copy of the sleep study results and the patient’s benefits for the oral appliance.  Please contact us to double check whether or not pre-authorization is required.  These benefits are a general quote from the insurance company and do not guarantee payment.  Actual payment will be based on the terms and conditions of the patient’s plan.

• Do you automatically obtain the pre-authorization for the oral appliance?

Since some patients may not qualify for an oral appliance or choose an alternate form of therapy, we do not automatically obtain the pre-authorization for the oral appliance.  After your office reviews the sleep study results with the patient and the patient elects to move forward with the oral appliance, please notify our office to start the pre-authorization process.  This notification can be done over the phone, via e-mail, or can be noted on a Super bill.

• How long does it take to obtain a pre-authorization?

It can take anywhere from a few days to a few months to obtain preauths.  Especially as we get your office set up within the medical insurance company’s system, the process is likely to take longer.

• How long does it take a claim to process?

Standard medical claims take 4-15weeks to process.  Appeals, requests for medical records and re-processing can take an additional 60-90 business days.  The first claims submitted on your behalf to each insurance company will likely take longer as well.

• Can we find out how much the insurance company will pay for the oral appliance?

Unfortunately, we will not find out the insurance company’s allowable amount until after the claim is processed.  Every insurance company uses a confidential usual, customary and reasonable (UCR) rate based upon the patient and provider’s demographic area.  Sometimes they will allow the amount in full and sometimes they will allow a lower amount.  Deductibles and co-insurances will be deducted from the insurance’s allowable amount.

• What happens if the oral appliance claim gets denied?

We will appeal any denied claim that has appeal rights.  The appeal process takes a minimum of 45 to 60 business days to complete.

• How does the dentist’s office get paid?

All insurance communication and payment goes directly to the dentist’s office.  Your office address is used on the claims and W9; thus, all payments will go directly to you.

• How/When are the billing services paid for?

You are required to fax a copy of any insurance communication and payment to our office.  Once a claim has been paid, we will send you a separate invoice for our compensation.