YOUR INSURANCE IN OUR OFFICE
Eric Phelps DDS is not a participating provider with medical or dental insurance companies in the airway practice. As a courtesy, we would be happy to file any necessary insurance forms or documentation to assist the processing of a reimbursement. Some medical insurance policies cover a portion of TMJ and sleep breathing treatments while some dental plans have limited coverage for TMJ - be sure to check with your dental carrier. We feel it is important for you to understand your plan and its payment allowances.
Once Dr. Phelps has developed a diagnosis and treatment plan for you, we will send the appropriate information to your insurance company to assist with required authorizations. Please keep in mind no insurance plan covers all costs.
Most have member service representatives available to assist in understanding your plan's specific benefits. Since Dr. Phelps is an out of network provider, your insurance company may be unwilling to provide any other information than the basic plan benefits to our office. Insurance contracts are between you, the member, employer and the insurance carrier.
We will attempt to obtain as much information as we can, however, the insurance company may limit the information they provide us. Therefore, we advise you to contact the insurance carrier to obtain the plan's specific benefit information so you can make an informed and educated decision while creating a payment arrangement.
TERMS AND DEFINITIONS
In-network or participating provider: The healthcare professional has a contract with your insurance company agreeing to a dollar amount for a service and adjusts the fee based on the contracted amount.
Out-of-network or non-contracted provider: The healthcare professional does not have a contract for services with the insurance company. There may be benefits available, however, the benefit is not determined until the claim is revised. Therefore, the insurance company is not able to provide the dollar amount for a service to an out-of-network provider.
HMO (Health Maintenance Organization) vs. PPO (Preferred Provider Organization) plans: With an HMO, you have benefits available only when you received services from an in-network or contracted provider. PPO plan allows benefits for both in and out-of-network providers. Occasionally, if receiving a service from an out-of-network provider or facility the benefit may be reduced but, there still maybe coverage of some dollar amount.
Deductible: The dollar amount that must be satisfied prior to the insurance plan making payment or reimbursement.
Co-Insurance: The percentage the member is responsible for covering after the deductible is met.
Reasonable and Customary limits or allowed amounts for services: The arbitrary amount an insurance company sets as the fee for a particular product, procedure, or service. (For example, We will bill them the full fee for each service, your benefit or coverage/payment will be based on the dollar amount they have chosen.)
Exclusions and limitations: There are times where an insurance plan or group will not provide any payment or allow any benefit for a particular diagnosis or service. Limitations are occasionally seen as a maximum amount an insurance company will allow or pay for a particular diagnosis or service. The limit can be either in the form of a dollar amount or percentage.
CPT (Current Procedural Terminology) code: The code or number that represents the service, procedure, or equipment being performed or provided on the claim form.
ICD 10 (International Classification of Diseases) - Diagnosis Code: The code or number that represents why the service, procedure or equipment was done or provided.