Navigating Insurance
We help you navigate your insurance
At TMJ & Sleep Therapy Centre of North Texas, we have treatment coordinators availablewho are specialists in maximizing the benefits of our patients’ insurance plans.
Prior to your first visit with us
Contact your insurance company to verify benefits. It’s important that you understand your coverage and your insurance plan’s payment limits. Below, we have outlined frequently used terms and definitions to help you do so. If you need help, do not hesitate to email or call us at 972-538-3777, and we’ll answer your questions to the best of our ability.
Need-to-Know Insurance Information
TMJ treatments, sleep disorder treatments, and breathing treatments are usually filed with medical insurance – not dental. We can file necessary documentation to assist processing insurance claims as a courtesy to our patients. In addition, once a diagnosis and treatment plan has been developed for you, we will help you with insurance authorizations as needed.
Dr. Shab Krish, DDS, MS is not a participating provider with medical or dental insurance companies, and is an out-of-network provider. As such, your insurance company may not provide information other than basic plan benefits to us. Please keep in mind that no insurance plan covers all costs.
Terms and definitions
In-Network Or Participating Provider
A healthcare professional who has a contract with an 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
A healthcare professional who 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 reviewed.
HMO Vs. PPO Plans
With an HMO, you have benefits available only when you receive services from an in-network or contracted provider. PPO plans allow 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 is still 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 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.
Additional Helpful Links
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