Insurance Coverage for Oral Orthotic Treatment

This letter is to give you information on insurance coverage for your visits in my office. At present I'm contracted with only three insurance providers, those are Harvard Pilgrim Health Plan, Medicare, Tricare, and some Blue Cross Blue Shield of MA plans. These providers will cover your evaluation only if you have met your individual plan requirements for necessary referral forms from your primary care physician. Some of your plans require referrals others do not; make sure you contact your insurer to find out what is necessary. All HMO plans require referral from your primary care physician.

Aetna: I am an Aetna provider in Massachusetts only, ID: 5156251. You must get a referral from your primary care MD.
Anthem: Anthem will not allow me contract status so you are responsible for all fees and insurance forms will be filed so that Anthem can reimburse you at their set fees (not necessarily mine)
Blue Cross Blue Shield of MA: HMO requires an “Out of Network” authorization from your Primary Care Physician. Your PCP must call: 1-800-327-6713 and request an out of network authorization to Dr. Gail Demko, provider # V04806. Appliances are only covered if I can get approval from this same Oral Surgery Utilization Review Board. The appliance fee includes 90 days of follow-up visits. Co-Pays vary. All PPO members will be held to out-of-network deductible and coverage. The first visit is out-of-pocket and payment is expected at the time of service.
Harvard Pilgrim Health Plan: I am a contracted provider for Harvard Pilgrim but you must get referrals for 3 visits from your primary care M.D. to provider # 9089.
Mass Health / Medicaid: I am not a Mass Health provider, I will not bill them; they will not cover any of your visits. Mass Health patients must bring payment with them on the day of the appointment and seek reimbursement from Mass Health.
Medicare covers evaluation appointments if you are referred by your physician. Medicare only pays for the first visit. I do not have a contractual agreement with Medicare durable medical goods, and do not qualify for one. This means that there is no coverage for your oral appliance in my private practice and you are responsible for all fees. Once your bill is paid in full, forms and instructions will be provided so you to seek reimbursement from Medicare.
Tricare: I am a contracted provider. You will require a referral from your Primary care Provider.

Tufts Health Plan: requires a referral for an ‘out-of network’ provider (IPA signature). My provider # is: 689604. These referrals cannot be electronically submitted, but must be ‘paper copies’. One copy should be faxed to my office at (617) 467-0712. Once I receive prior authorization for an appliance, Tufts includes 6 months of follow-up appointments.

They only cover 80% of the fee for an oral device. Tufts Navigator pays variable fees that I have never figured out, but much less than Tufts.

United Health, Blue Cross Not MA, and other private companies require pre authorization for the initial patient evaluation. Without pre authorization, you will need to pay the full fee and seek reimbursement.
CIGNA claims to have an in-net provider. Make sure that you are getting a custom fabricated device from a dentist trained in Sleep Dentistry.

Insurers will not pay for oral appliances that are fabricated to treat primary snoring, and many have specific guidelines determining the diagnosis of obstructive sleep apnea. If you do not meet the guidelines as set forth by your insurance company, your visit will not be covered.

All insurance companies require prior authorization for fabrication of any appliance. Prior authorization requires submission of records from your sleep physician, copies of your sleep studies, a record of CPAP trial and a letter explaining FDA accepted oral appliance. The necessity of CPAP trial will be waived only if there is a medical reason for not trying CPAP. All companies will REQUIRE a letter of medical necessity. This letter must come from your sleep physician

Few insurers to date have covered necessary follow-up appointments (12, 18 and 24 months) and repairs of appliances. Please call your insurer about their coverage for these procedures, or expect to be responsible for the fees. The appointments are necessary to determine serious side effects as quickly as possible. Co-pays are substantial

Patients who have medical insurance through companies with which I do not contract will be required to pay for my services at the time they are rendered and all forms necessary for insurance reimbursement will be sent to you so that you can deal with your own insurance company.

United Healthcare WARNING!!!! I am not in-network with United Health regardless of what their representatives say.
DO NOT BELIEVE THEM

Denist1

Dentists play an important role in the team approach to the treatment of obstructive sleep apnea.

Physicians, dentists, psychologists, and respiratory therapists all pool their knowledge to treat each patient appropriately and effectively.

Dentists who are specifically trained in aspects of sleep medicine and have a command of multiple appliance modalities are of great help to physicians in treating patients with sleep disordered breathing problems.

AVALABLE OFFICE HOURS:

Monday – Friday
8:30 A.M. – 2:30 P.M.
In Massachusetts Call:
617-964-4028
or click here
 In Indiana Call:
317.842.9866

The National Center on Sleep Disorders Research, can provide you with sleep education materials. As well as publications on heart, lung and blood research:
Two Rockledge Center, Suite 7024, 6701Rockledge Drive, MSC 7920, Betesda, MD 20892-7920
(P)301.435.0199 /
(F) 301.480.3451
www.nhlbi.nih.gov/about/ncsdr/

Information about sleep disorders may be obtained from NHLBI:
NHLBI Information Center
P. O. Box 30105, Bethesda, MD 20824-0105
(P) 301.251.1222 / (F) 301.251.122
www.nhlbi.nih.gov/