If you’re planning a major oral surgery, then you’re probably wondering whether your medical or dental insurance will cover the cost. Oral surgeries can include the removal of diseased or impacted teeth, dental implants, biopsies, tumor removals, repair of trauma, and other surgical issues involving the bones and soft tissues of the face. These surgeries can be very expensive, so it’s important to know how your insurance can help with the cost.
Having dental insurance offers many benefits like lowered dental care costs and the ability to stay on top of your oral health. Also, keep in mind that, within the wide range of procedures and treatments performed in a dental office, your medical insurance provider may consider many of them as medically related. For many oral surgeries and certain dental-related procedures, your medical insurance may cover all or a portion of the healthcare bill.
Your dental health can affect the rest of your body, and your overall health can affect your oral health. When you require a serious dental procedure, like oral surgery, some of the costs may be covered by both your dental insurance plan and your medical insurance plan. Whether or not your medical insurance covers a dental-related procedure will depend on your insurance provider and plan coverage. In most cases, medical insurance plans will cover some major oral surgery procedures.
We recommend that you have a conversation with your dentist or dental specialist office staff to see if they have experience filing medical claims. They should be able to give you an idea of the likelihood of receiving coverage and help you obtain a predetermination of benefits. You can also talk directly with your medical insurance provider to see if your procedure is covered, get an estimate of how much they will pay, and gain a better sense of what out-of-pocket costs to expect. Be sure to do the same with your dental insurance provider, as they may provide a higher level of coverage for such a procedure.
Most common oral surgeries are covered, at least in part, by your dental insurance provider. However, this depends on the specific type of surgery you need, your dental plan, and your level of coverage.
Your medical insurance may also pick up the cost in full or part for medically-related oral surgery procedures depends on your plan, medical health status, and the type and degree of difficulty of the surgery. Costs may be covered for diagnosis, treatment, or prevention of a medically-related oral condition or for rehabilitation of lost skills related to the problem.
Do I need to get treatment from an oral surgeon, or can a general dentist perform the service I need?
Oral surgeons and other dental specialists, as well as general dentists, can bill medical insurance for certain procedures. Look at your specific dental insurance plan information to see if the treatment will be covered by dental insurance or if you should get your medical insurance provider involved.
In some cases, both your dental and medical insurance may pay a portion of your treatment. When that's the case, you or your dental provider can send a request for a pre-treatment estimate to one or both insurers to get a better understanding of the costs you will acquire.
Which dental procedures are covered by medical insurers?
Depending on the circumstances, your insurance provider may bill different dental procedures as medically-related dental procedures. Some examples include:
Surgical treatments - Difficult wisdom tooth extractions and other complex tooth removals, soft and hard tissue biopsies, frenectomies on newborns, correction of facial deformities, cancer-related treatment, and dental implants.
Dental/facial trauma - injuries resulting from automobile or other accidents, teeth have been knocked loose or knocked out.
Diagnostic procedures - certain x-rays (non-routine), bacterial testing, and testing used to discover the source of oral and myofascial pain.
Non-surgical medical procedures - emergency treatments for inflammation and infection, drainage of abscesses, general anesthesia for surgeries, and appliances for TMJ or sleep apnea.
Many common dental treatments can be billed as medical treatments under certain circumstances. That being said, submitting your oral surgery claims to your medical plan can be a good way to extend your health care dollar. However, the medical claim submission process is different and could be more difficult than the dental insurance claim process. It usually requires more documentation and proper medical coding of procedures from the provider. To help make the submission process easier, you can ask if your dental provider is familiar with submitting claims to medical insurance.
Note that oral surgeons will typically have more experience submitting medical claims than general dentists.
This claim submission process will require coordination between your dental insurance provider and your medical insurance provider. It’s considered coordination of benefits (COB) similar to the claim submission process when you have two dental insurance plans. Some types of medical insurance policies require that your provider bill the dental insurance company first, and then once that claim is processed, you can file a claim toward medical insurance. It is important to make sure that coordination takes place even when your medical and dental insurance is covered by the same insurance carrier.
Also, keep in mind that medical insurance could carry high deductibles that may need to be satisfied before any payment is made. If you have questions, we recommend talking with your oral surgeon or dentist's office staff or contacting your medical insurance provider directly.
https://www.ada.org/~/media/ADA/Public%20Programs/Files/Documenting_to_Support_Medical_Necessity_for_Pediatric_Professional.pdf?la=en [PDF]. (n.d.). American Dental Association
https://www.mass.gov/doc/orthognathic-surgery-0/download. (n.d.). MassHealth