Allowable charge:  the amount that network doctors and other health-care providers contracted by your health plan have agreed to accept as full payment for covered health-care services and supplies.

Benefit:  The portion of the cost for covered health-care services and supplies that your health plan is responsible for paying.

Claim:  The paperwork that is submitted to the insurance company to be paid. At the end of each appointment we print out a claim form for you to submit to your insurance. This can be filled out and mailed to the insurance company and will be considered a claim. It is usually only one page in length.

COB: Coordination of Benefits. This is the technical name given when a patient has more than one insurance and the insurance company is willing to move the claim on to the next insurance to be processed. This usually happens when a patient has a primary insurance and a secondary insurance.

Coverage:  The range of health-care services and supplies for which your health plan provides benefits.

Covered Benefits:  This refers to the benefits that are covered by your individual insurance plan.  Each insurance plan is different and every insurance company decides differently how they will cover procedures.  If your policy states that it is a covered benefit, then they will pay a percentage of the entire cost.  The percentage covered will be determined directly by your policy.  If it is not a covered benefit, your insurance will pay no portion of it.

CPT code:  Current Procedural Therapy code.  This is the national medical coding used by all medical insurances to identify the procedures done in our office.  This is also how insurances identify the amount they will reimburse for that charge or service.  At our office, we use CPT codes rather than dental codes.  We find that the medical portion of most insurances cover more for TMJ than dental coding does.

Dental Code:  Dental codes will always begin with a “D” and have 4 numbers following.  Some dental codes will have zeros at the beginning instead of a “D”.  This is also acceptable.  Dental coding is used nationally by all dentists to identify the charge or service that was provided.

DOS: Date of Service. This is the actual date that the patient was seen in the provider’s office for treatment. The Date of Service is important when asking insurance questions, as they will only have information on the dates that have been submitted and received by their office. If they don’t have the information, then it is possible that the claim was lost or needs to be submitted a second time.

Durable Medical Equipment (DME): This is the technical name for the appliances that we use here in our office. Durable medical equipment (DME) is equipment that is primarily and customarily used to serve a medical purpose, can withstand repeated use, and is appropriate for use in the home. Some examples of DME include hospital beds, walkers, wheel chairs and oxygen tents. Some insurances require a preauthorization be made before any Durable Medical Equipment is issued to you. Usually this preauthorization is needed only when it is $300 or more in price. All of our appliances fit this criteria. Preauthorization will usually require a description of the device, what it is to be used for along with diagnosis codes and other CPT codes.   

DX code:  Diagnosis code. This represents the coding used for each diagnosis that the doctor has prescribed for the patient. The diagnosis is important for reimbursement from insurance and is always important to include when filling out.  It is usually the same as the ICD-9 code. 

E.O.B.: Explanation of Benefits. Letter or statement that the insurance will send to the provider and to the patient regarding any claims that the insurance has received and processed. The purpose of the EOB is to show an itemized statement of each charge and the portion of that charge that was paid. The EOB will also have a reason for payment of each charge.  Insurance sends this statement for the patient to see what has been paid or what the insurance has received. If there is no EOB sent to the patient, then it is likely that the insurance never received the claims. If DOS are missing on the EOB, then it is likely that the insurance didn’t receive claims yet or are still processing them.

Exclusion:  A name for the benefits that are not covered in your individual policy. When your individual policy doesn’t cover certain procedures or certain treatments, it is excluded from that policy and will not be covered. There is usually no way to avoid an exclusion in your policy, as that specific policy does not pay for those treatments and procedures.

ICD-9 code: The International Classification of Diseases, Ninth Revision. These are the codes used to classify and index all medical diagnoses. This is the national standard coding that all insurances and billing will understand and be able to work with.  If ever asked for your diagnosis, there is a number and name for each code.

In-Network Provider:  Most doctors will contract with different insurances to become an in-network provider.  The insurance will contract with the doctor to pay a certain price for certain procedures.  Because the insurance and the doctors have this contract the insurance will usually pay at a better rate when the patient is seen by in-network providers.  If the doctor is not an in-network provider, then the insurance may choose to pay at a lower rate or not at all. Dr. Spencer is only contracted with Medicare to be an in-network provider.  

Letter of Medical Necessity:  A letter written by the provider (doctor office) to the insurance to explain the medically necessary reasons for the procedures performed or to be performed.  This letter can be requested from the patient or the insurance and only is written after we have seen you as a patient. This letter specifies the diagnosis and the reasons why the doctor feels that these procedures are necessary for the patient. We can write a Letter of Explanation if the patient has not yet been seen in our office. 

Network:  A group of doctors, hospitals and other health-care providers that have been contracted by your health plan to provide health-care services and supplies at agreed upon amounts called “allowable charges.”

Out-of-Network Provider:  Some insurances require that patients are only seen by doctors that have contracted with the insurance for a specific rate.  If the patient is seen by a doctor that is not in this contract, it is considered an out-of-network provider.  In this case the insurance will not pay or reimburse at the best negotiated rate.  They will usually pay at a lower rate or not at all, which forces the patient to pay for the entirety of the office visits.

Out-Of-Network Waiver:  This is a letter that is written by the provider’s officer to the individual insurance upon request.  It is written when the insurance or patient requests a letter to provide a written explanation why the doctor is not a provider for the insurance.  The letter explains that there are no other doctors in the area that provide this service. Our patients have no other doctors to choose from for these treatments. The letter will also request that the insurance consider the doctor at an in-network rate, rather than the out-of-network rate that will reimburse less. If your insurance requests that an out-of-network letter be provided then we are happy to write the letter.  When the insurance receives an out-of-network waiver it is very possible that they will consider these fees at the in-network rate.

Out-of-pocket expenses: Costs that are paid by you, the patient, not your health plan.  Such as the following:
   

• Copayment (copay): A set fee your health plan may require you to pay your doctor or other health-care provider at each visit for certain covered services.
• Deductible:  A fixed amount your insurance plan may require you to pay for certain covered services and supplies each year before your health plan starts paying specified benefits.  Co-pays are not credited toward your deductible.  Most office visits will have a co-pay of $20 to $40, and the patient will be billed for the remaining amount of the office visits until their deductible is met.  The deductible will need to be met (paid for) before the patient can be reimbursed by their insurance for all office visits with any doctor. 

Predetermination:  This occurs when insurance companies require information and an approval code before treatment begins.  Some insurances require a predetermination (preauthorization) for visits with us.  This must be completed before the actual appointment.  The patient may call their insurance to see if their insurance needs any information to be processed before they come in for treatment.  For predetermination most insurances will need a referral from your regular doctor, a description of what you are being seen for and the reason for treatment with us.  If the insurance needs information for the services that we provide, we are happy to give these.

Provider:  A doctor, hospital, or other medically licensed or medically certified person or facility that provides health-care services or supplies.

Sleep Study:  This is a study that is usually ordered by a sleep doctor when a patient shows signs of sleep apnea or other related symptoms.  The sleep study is usually performed at a sleep lab or at the hospital.  A sleep study should also be taken before a patient is seen by our office.  Dr. Spencer and his associates will request a sleep study before the patient’s initial examination.  A review of this report is required by our office before being treated for sleep apnea as a new patient.

Tap Packet:  This is a packet of information we have specifically designed for our sleep patients who are receiving a TAP appliance. Most of our patients will need to send the TAP packet right after their first office appointment.  They will include it with their first claim and a copy of their Sleep Study for predetermination before they return to receive the actual appliance. Our office will let the patient know to download and send it with your sleep study for insurance reimbursement. Most insurances require this information after your first visit with us as the patient prepares to receive the actual splint.  It is about 15 pages long and the entire packet should be included.  It is a full explanation for the use of the TAP appliance (or any oral appliance) for sleep apnea and gives professional consideration on its usage for healing medicinal and curative power for your individual insurance. This will help to give our patients better reimbursement.

TMD:  Temporomandibular Joint Dysfunction.  This is the dysfunction of the jaw joint and the technical name for the diagnosis of jaw joint problems.  (TMJ and TMD may be used interchangeably).  When being treated in our office for jaw problems TMD or TMJ are the diagnosis most associated with all jaw pain and dysfunction.

TMJ:  Temporomandibular Joint.  This is the jaw joint right below the ear that can be the cause of facial pain, headaches and jaw pain related symptoms.  Dr. Spencer’s Office focuses on the therapeutic remedies to treat TMJ and TMD.