Insurance
Here at the Craniofacial Pain Center we care that our patients are able to understand and receive the best possible reimbursement from their insurance. This insurance section has been provided with many links to help each patient obtain the necessary skills for working with their insurance properly and to fully understand the process. We hope this information is helpful, easy to follow, and clear to use.
Q. Do you accept my insurance?
A. Because Dr. Spencer and Dr. Murphy are in the unique position of being dentists treating TMJ, which is considered a medical condition, they are unable to contract with insurance companies for payment. We are therefore unable to accept insurance as they will not pay for many of the treatments we offer. We do however, assist our patients with submission to their insurance and submit your claims directly to your insurance carrier as a courtesy.
Q. Will my insurance pay for this? Do I have benefits/coverage for TMJ treatment?
A. Each insurance policy is different. Many individual policies do have benefits regarding the treatment for TMJ/TMD. If your policy has an exclusion for the services provided in our office, your insurance will not cover your treatment. We suggest that you call your insurance or look through your benefits booklet. Some things to ask and look for:
A. We do submit insurance claims for our patients as a courtesy. Or, if you'd like we can instruct you on how to do this yourself. Sometimes there is an advantage to individuals submitting their own claims so that they can keep track of the claims process on their own.
Q. Are Dr. Spencer and Dr. Murphy Providers on my Medical Insurance? As dentists, Dr. Spencer and Dr. Murphy are not able to contract with medical insurance carriers.
Q. If Dr. Spencer and Dr. Murphy are not contracted providers, can I see them?
A. Some policies require you to initially use their “contracted or preferred providers”. However, it is possible to see someone outside of the network. Some insurances have an out-of-network rate which requires additional information to be submitted for this allowance. Check with your insurance carrier to see what their guidelines on out-of-network providers are.
Q. Does insurance consider TMJ/TMD treatment as medical or dental?
A. The treatment for TMJ/TMD usually has better coverage when submitted as a medical procedure rather than a dental procedure. Even though the doctor is a dentist, the actual treatment is linked to a medical diagnosis and the medical insurance will usually have better coverage for these services.
Q. Can these procedures be billed through my dental insurance?
A. If you have benefits for the treatment of TMJ/TMD, the medical portion of your policy usually provides much better reimbursement than your dental policy. However, if you have no medical benefits, it is easy for us to code the billing for dental submission.
Q. What all do I need to come in for an initial evaluation?
A. To set up an initial appointment you will need to call our office and reserve a time. It is very important for insurance purposes to have a doctor referral to come see us. Most insurance companies like to see that the patient has been referred by a regular dentist or physician. Some insurance companies require pre-authorizations for some procedures. (For more additional info on pre-authorizations see Before Coming In and Prior Authorization links).
Q. How is TMJ treated? What is typical treatment for TMJ?
A. At our office we offer conservative, non-surgical treatment by gradually moving the jaw back to its correct position. Dr. Spencer and Dr. Murphy are not oral surgeons and our treatment methods do not include breaking the jaw or the use of surgery to correct TMJ. The majority of our patients come in for a comprehensive exam to be diagnosed and have a treatment plan prepared. At this appointment the patient visits with the doctor to find out the exact cause and location of the pain and dysfunction. The doctor will perform a complete head and neck examination to find the best way to treat the patient.
If further treatment is indicated, oral appliances (splints) will be made in a lab for the patient to wear in the mouth. Usually this treatment is for the next 4 to 6 months. They can be needed on a more permanent basis if conditions require it. These appliances fit in the mouth (similar to retainers) and are worn as directed to move the jaw into the correct position and realign the bite. Our patients are usually fit with two splints. One splint will be worn during the day (daysplint), while the other is worn only at night (nightguard). The patient will then typically return every few weeks for follow up and adjustment appointments after they have received the splints. These appointments allow for adjustment to the splint which will slowly correct the positioning of the jaw while reducing the symptoms.
Depending on the severity and symptoms, some of our patients will only receive one splint to treat the jaw. This treatment follows the same guidelines as patients that wear two splints. Most of our patients complete this therapy process within 6 months to a year.
Q. Why won’t my insurance cover treatment for “TMJ/TMD?”
A. Insurance companies make choices all the time regarding what they will or won’t cover. These decisions are usually financial in nature. Insurance coverage varies from state to state and from company to company.
“Temporomandibular Joint Dysfunction” is a non-specific diagnosis. Even when a specific diagnosis is made, such as tension type headache, capsulitis of the TM joint, disc displacement or even degenerative arthritis, many insurance companies will still deny coverage based on their “TMJ exclusion.”
The history behind this outdated principal dates back decades. “TMJ” became a common diagnosis in the 60’s and 70’s. It was not at all clear what caused these problems and treatments were unspecific and often very expensive. Since the disorder was considered more of a medical problem then a dental problem, medical insurance started to be billed by dentists for the diagnosis and treatment. In some cases dentists would recommend orthodontics or crowning of many of the teeth as treatment. These procedures were costly, and insurance companies did not feel that they were really medically necessary. Because of “a few bad apples,” insurance companies developed “TMJ exclusions” to protect their profits. BlueCross of Idaho continues to have a “TMJ exclusion” on virtually all of their polices (except for a few State and local government policies). This is very disappointing for the patient who has seen multiple practitioners for their pain, including ENT’s, neurologists, family doctors, physical therapists, pain doctors, etc.—all of whom were covered by their insurance, and then find out that treatment for the same pain problem is not covered in our office due to a TMJ exclusion.
Over the years some insurance companies have created a “TMJ benefit” which is usually a limited amount of coverage, similar to the coverage limits on physical therapy.
In 23 States patients and doctors have gone to their State legislature to mandate changes. In these 23 States laws have been passed that require insurance companies to cover the diagnosis and treatment of TMJ. The legislature has not yet done this in Colorado, but our office would certainly support any grass roots efforts by our patients. After all, you just want to receive the benefits that you pay for.
Q. What if you don’t diagnose my problem as “TMJ” and just use some other diagnosis code?
A. Most insurance companies don’t seem to care what your diagnosis actually is. Dr. Spencer and Dr. Murpy often joke with patients that “I could diagnose you with ingrown toenail and your insurance company will deny your claim saying that you have a TMJ exclusion.” Of course this is ridiculous, but it is closer to the truth than you might imagine. As mentioned above, even when a patient has been treated for years for a condition, (headache, for example) by multiple different care givers, all of whom have been covered by insurance, once the patient is referred to our office the headache diagnosis is re-interpreted as “TMJ” (even though no TMJ diagnosis is made). We believe this is because diagnosis and treatment of TMJ is virtually always performed by dental professionals—which makes it easy for the insurance company to pick these claims out.
Frequently Asked Questions
For the treatment of TMJ
For the treatment of TMJ
Q. Do you accept my insurance?
A. Because Dr. Spencer and Dr. Murphy are in the unique position of being dentists treating TMJ, which is considered a medical condition, they are unable to contract with insurance companies for payment. We are therefore unable to accept insurance as they will not pay for many of the treatments we offer. We do however, assist our patients with submission to their insurance and submit your claims directly to your insurance carrier as a courtesy.
Q. Will my insurance pay for this? Do I have benefits/coverage for TMJ treatment?
A. Each insurance policy is different. Many individual policies do have benefits regarding the treatment for TMJ/TMD. If your policy has an exclusion for the services provided in our office, your insurance will not cover your treatment. We suggest that you call your insurance or look through your benefits booklet. Some things to ask and look for:
- Is there an exclusion for the treatment of TMJ/TMD and what would be covered as you come in for treatment.
- What is the amount of deductible you have left to pay.
- Find out which procedures and office visits would be covered and at what rate.
- Please make a note of the person you spoke with, what they told you and the day you called.
A. We do submit insurance claims for our patients as a courtesy. Or, if you'd like we can instruct you on how to do this yourself. Sometimes there is an advantage to individuals submitting their own claims so that they can keep track of the claims process on their own.
Q. Are Dr. Spencer and Dr. Murphy Providers on my Medical Insurance? As dentists, Dr. Spencer and Dr. Murphy are not able to contract with medical insurance carriers.
Q. If Dr. Spencer and Dr. Murphy are not contracted providers, can I see them?
A. Some policies require you to initially use their “contracted or preferred providers”. However, it is possible to see someone outside of the network. Some insurances have an out-of-network rate which requires additional information to be submitted for this allowance. Check with your insurance carrier to see what their guidelines on out-of-network providers are.
Q. Does insurance consider TMJ/TMD treatment as medical or dental?
A. The treatment for TMJ/TMD usually has better coverage when submitted as a medical procedure rather than a dental procedure. Even though the doctor is a dentist, the actual treatment is linked to a medical diagnosis and the medical insurance will usually have better coverage for these services.
Q. Can these procedures be billed through my dental insurance?
A. If you have benefits for the treatment of TMJ/TMD, the medical portion of your policy usually provides much better reimbursement than your dental policy. However, if you have no medical benefits, it is easy for us to code the billing for dental submission.
Q. What all do I need to come in for an initial evaluation?
A. To set up an initial appointment you will need to call our office and reserve a time. It is very important for insurance purposes to have a doctor referral to come see us. Most insurance companies like to see that the patient has been referred by a regular dentist or physician. Some insurance companies require pre-authorizations for some procedures. (For more additional info on pre-authorizations see Before Coming In and Prior Authorization links).
Q. How is TMJ treated? What is typical treatment for TMJ?
A. At our office we offer conservative, non-surgical treatment by gradually moving the jaw back to its correct position. Dr. Spencer and Dr. Murphy are not oral surgeons and our treatment methods do not include breaking the jaw or the use of surgery to correct TMJ. The majority of our patients come in for a comprehensive exam to be diagnosed and have a treatment plan prepared. At this appointment the patient visits with the doctor to find out the exact cause and location of the pain and dysfunction. The doctor will perform a complete head and neck examination to find the best way to treat the patient.
If further treatment is indicated, oral appliances (splints) will be made in a lab for the patient to wear in the mouth. Usually this treatment is for the next 4 to 6 months. They can be needed on a more permanent basis if conditions require it. These appliances fit in the mouth (similar to retainers) and are worn as directed to move the jaw into the correct position and realign the bite. Our patients are usually fit with two splints. One splint will be worn during the day (daysplint), while the other is worn only at night (nightguard). The patient will then typically return every few weeks for follow up and adjustment appointments after they have received the splints. These appointments allow for adjustment to the splint which will slowly correct the positioning of the jaw while reducing the symptoms.
Depending on the severity and symptoms, some of our patients will only receive one splint to treat the jaw. This treatment follows the same guidelines as patients that wear two splints. Most of our patients complete this therapy process within 6 months to a year.
Q. Why won’t my insurance cover treatment for “TMJ/TMD?”
A. Insurance companies make choices all the time regarding what they will or won’t cover. These decisions are usually financial in nature. Insurance coverage varies from state to state and from company to company.
“Temporomandibular Joint Dysfunction” is a non-specific diagnosis. Even when a specific diagnosis is made, such as tension type headache, capsulitis of the TM joint, disc displacement or even degenerative arthritis, many insurance companies will still deny coverage based on their “TMJ exclusion.”
The history behind this outdated principal dates back decades. “TMJ” became a common diagnosis in the 60’s and 70’s. It was not at all clear what caused these problems and treatments were unspecific and often very expensive. Since the disorder was considered more of a medical problem then a dental problem, medical insurance started to be billed by dentists for the diagnosis and treatment. In some cases dentists would recommend orthodontics or crowning of many of the teeth as treatment. These procedures were costly, and insurance companies did not feel that they were really medically necessary. Because of “a few bad apples,” insurance companies developed “TMJ exclusions” to protect their profits. BlueCross of Idaho continues to have a “TMJ exclusion” on virtually all of their polices (except for a few State and local government policies). This is very disappointing for the patient who has seen multiple practitioners for their pain, including ENT’s, neurologists, family doctors, physical therapists, pain doctors, etc.—all of whom were covered by their insurance, and then find out that treatment for the same pain problem is not covered in our office due to a TMJ exclusion.
Over the years some insurance companies have created a “TMJ benefit” which is usually a limited amount of coverage, similar to the coverage limits on physical therapy.
In 23 States patients and doctors have gone to their State legislature to mandate changes. In these 23 States laws have been passed that require insurance companies to cover the diagnosis and treatment of TMJ. The legislature has not yet done this in Colorado, but our office would certainly support any grass roots efforts by our patients. After all, you just want to receive the benefits that you pay for.
Q. What if you don’t diagnose my problem as “TMJ” and just use some other diagnosis code?
A. Most insurance companies don’t seem to care what your diagnosis actually is. Dr. Spencer and Dr. Murpy often joke with patients that “I could diagnose you with ingrown toenail and your insurance company will deny your claim saying that you have a TMJ exclusion.” Of course this is ridiculous, but it is closer to the truth than you might imagine. As mentioned above, even when a patient has been treated for years for a condition, (headache, for example) by multiple different care givers, all of whom have been covered by insurance, once the patient is referred to our office the headache diagnosis is re-interpreted as “TMJ” (even though no TMJ diagnosis is made). We believe this is because diagnosis and treatment of TMJ is virtually always performed by dental professionals—which makes it easy for the insurance company to pick these claims out.