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Tip of the Week: How to know what is required for medical coverage - 4-13-15 to 4-17-15

Monday, April 20, 2015

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How to find and read medical policies

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Learn the Lingo of Medical Billing

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Benefit Verifications

View NPM Study Group:

Objective Look at Medical Billing Services

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Tip of the Week!

How to know what is required for medical coverage


Want to know what coverage criteria an insurer requires before even getting on the phone with them? Good news is - most medical insurers will post their medical policies right on their website!

A medical policy is intended to provide guidelines and coverage criteria for:

  • Services
  • Equipment
  • Technology
  • Procedures

Examples of information you may find in a medical policy are:

  • What services are covered, and not covered
  • Coverage criteria to meet medical necessity
  • CPT & HCPCS codes covered, and not covered by policy
  • Diagnosis codes covered, and not covered by policy
  • Additional billing/coding information – i.e. modifiers, appliance guidelines
  • Definitions & Resource
  • Example documentation

A medical policy is different that a patient’s coverage policy

  • The medical policy is criteria and guidelines set by the insurer
  • The patient’s coverage policy is what specific benefits that patient’s policy carries

To find the medical policy for the treatment you are looking for:

  • Start with the insurer’s main website (or website on patient’s medical card if you have it!)
  • Locate the “providers” section (you will generally also find “members”, “employers”, investors”, etc sections of the site)
  • Locate the medical policies section (sometimes  labeled “policies procedures & guidelines”, “practice resources”, “coverage policies”, “clinical policy bulletins” (CPB’s), local coverage determinations” (LCD’s)).
  • Search for the subject you are treating! i.e. sleep apnea, temporomandibular disorders, pain, accident, oral surgery, etc
  • If a policy is not available online, you can call the insurer to request a copy be faxed/mailed/e-mailed to you

Below is an example of language you may find in a medical policy (the example below is a policy related to oral appliances for obstructive sleep apnea):

Looking for more in-depth training for Medical Billing in Dentistry?

Current clients receive discounts on education!
Call us at 800-879-6468 or e-mail us at to learn more

Join NPM for our "Successful Medical Billing in Dentistry" CE courses held across the country!

Our next course Medical Billing course coming up is April 1
7th & 18th in beautiful San Diego, CA!

There are plenty of other dates and cities if that one doesn't fit your schedule:

Watch any past NPM Study Group on demand!

The sessions are organized into categories to help you find what you're looking for - or something you didn't even know you were looking for!

1. Sleep Apnea Training

Dental practice training for managing, treating and medical billing for obstructive sleep apnea with oral appliance therapy

2. TMD-TMJ Training

Training for dental practice for managing, treating and medical billing for TMD/TMJ services - temporomandibular joint disorders

3. Oral Surgery Training

Training for medical billing for medically necessary oral surgical services for the dental practice

4. General Medical Billing Training

Various general medical billing in dentistry training for the dental practice

5. Marketing Training
Marketing for medically necessary procedures in the dental practice training

6. Training - misc. topics

Misc. topics for training for dental practices treating and billing for medically necessary procedures

7. Recorded E3 Full Webinars
Full length training on DentalWriter software by treatment type

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