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3 times a dentist should file a medical claim versus a dental claim

medical claim
Originally published on the Dental ClaimSupport Blog

When does medical insurance cover the dental work your team performed, and how do you know? Not only is understanding insurance claims confusing, but knowing what kind of insurance claim to file can be confusing, especially when it’s medical versus dental. Welcome to the dental billing world! 

Really though, determining when you’re going to file a dental claim versus a medical claim can be a huge hang-up for dental teams. It’s hard to know when the right time for each claim is, and if you get it wrong, there could be delays on when the dental practice gets paid. 

This is a common mistake we see as a dental billing company, and helping offices understand this distinction is crucial to getting paid accurately by insurance in a timely manner. 

After you read this article, you will know when you should file a medical insurance claim instead of a dental insurance claim and when you would file a medical claim as primary insurance and a dental claim as secondary insurance.

How do you bill medical insurance for dental treatment?

The process for filing a dental claim and a medical claim has a few differences. A medical claim is completed on CMS 1500 form while a dental claim is completed on an ADA form. A medical claim uses CPT codes while a dental claim uses CDT codes. You can cross-code these claims if you’re filing both, but that’s a rabbit hole we won’t go down in this article. 

Why would you file a medical insurance claim at a dental practice?

There are a few instances where you need to file a medical claim for dental services. 

medical claim

1. Oral surgery 

A patient needs oral surgery; let’s say the patient has Guardian dental insurance as an example. If the dentist performing the procedure is out-of-network with Guardian dental insurance, it is mandatory for the medical insurance to be filed as primary.  

The dental provider will then get the denial from that medical carrier saying there are no oral surgery benefits, and you will then have to submit this denial to the patient’s dental insurance with that explanation of benefits from medical in order to get reimbursement from the dental insurance carrier. 

Even oral surgeons can outsource their insurance billing. Learn how specialty dentists still need help with getting insurance claims paid in our Learning Center.

The details across insurance policies are different, which is why it’s important to verify your patient’s insurance benefits before they come into the office. 

2. Trauma (broken jaw, broken tooth, or teeth)

Oral trauma is another reason to file a medical insurance claim versus a dental insurance claim. In most cases, if the reason for the procedure is due to an accident, you would file a medical claim. 

It’s also a good rule of thumb to remember: the more serious a procedure is, the more likely it should be filed as a medical claim. 

This excludes procedures such as fillings, crowns, root canals, or what you would call a typical or day-to-day treatment at your dental practice. If the patient has to be put under anesthesia, it is filed under medical insurance.

3. Pathology 

Dentists perform biopsies when needed to check for diseases inside of teeth, gums, and around the mouth. 

So if you’re submitting a claim for a biopsy, you typically want that to go to medical insurance. If results indicate cancer or another medical condition, medical insurance is responsible for any treatments that are necessary. Whether the condition in the mouth or also involves the head, neck, oral cancer would be covered under the medical plan. 

However, caveats exist of course. Medical is typically the primary insurance for pathology, but that doesn’t mean you’ll never file dental insurance claims. Even though medical pays as primary, you can cross-code to dental and there are instances, depending on the policy, where dental will pay as secondary. 

medical claim

When in doubt, you can ask the insurance companies where to file claims

Knowing whether to file medical or dental claims can be very confusing, but here’s the good news: you can always call and ask. 

This is a common source of confusion, so when in doubt just call the medical and dental insurance companies to confirm which to send to. If you don’t make a call and you just submit dental when it should be medical, you will receive an explanation of benefits back that will clarify: “Medical is primary, please submit to medical and start the process over.” 

Medical insurance oftentimes has a timely filing limit of 3-6 months, instead of the year-long timely filing limits in many dental plans. So you will want to track medical claims especially carefully to avoid denials due to time limits.

If you want to appeal a denied claim, should you close it out? Learn the answer in our Learning Center.

Ready to file more claims with confidence at your dental practice?

The big reason to know when to file medical versus dental claims is to avoid denials and collect full payment for everything your dental team has worked hard to perform. There are several instances where you would file a medical claim over a dental claim, and being familiar with the most common times you would do this will help you avoid denials and make your practice successful in continuing to provide care. 

You now understand how to differentiate these claims yourself, but Dental ClaimSupport is also a resource if you need help getting your claims paid by medical and dental insurance. 

Dive deeper into medical billing and how to avoid mistakes as a dentist by checking out our article, “Medical billing for general dentists: 5 common errors to avoid.” 

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