Books or Other Resources on How to File Successful Health Insurance Claims?

[TopHatFox]

Here's the deal: at the moment, I have no idea how to file a claim with a health insurance company that is likely to convince them to pay for treatment they sometimes cover. The treatment is orthognathic surgery to fix an overbite, teeth wearing, jaw pain, etc. -- the health insurance company has an exception that states how they will only pay for orthognathic surgery if it's a problem that can't be fixed with orthodontia alone (it can't) and if it is required for "significant medical reasons/function" (whatever the hell significant means).

So, I'm wanting to optimize my chances of getting this 20-30K process paid for by insurance so I can pay maybe 3-5k + 5k for orthodontia instead of , say, 25-35k total (and yes, this is necessary - my front teeth are wearing, jaw clicks, and it stinks + is slightly depressing).

What do you think: what's the best way to file claims with treatments/operations ambiguously covered by insurance? What do they look for in a successful claim? I imagine it's their intent to keep their float money invested, so perhaps I need to be so good in my application that I become a liability they're willing to pay for to keep me from, hm, suing. Thoughts? Resources? Experiences?

[jennypenny]

Will the oral surgeon (?) file the claim for you or do you need to pay in full and file for reimbursement? Will they get a pre-certification for you?

If you don't know, call them and ask. Most will get a pre-cert and tell you what you'll be expected to pay. DH had extensive work done over the past year kinda similar to yours. His dentist and surgeon worked together to get pre-approval for all of the procedures, told him how much he would owe out-of-pocket, and filed the claim after each visit. DH was expected to pay his share on the date of each service.

If they won't get a pre-cert or help you file, then my first suggestion would be to find another doctor. My second suggestion would be to call the insurance company and find out how you can get approved for the procedure. * There's no way I would have anything that expensive done without getting the insurance company's pre-cert in writing first.

Be upfront with everyone. You're not trying to get away with anything. You have a problem that needs correcting and you're trying to make sure the insurance company will pay for at least most of it before you have the procedure done.

* make sure you have the procedure codes and exact diagnosis when you call (get them from the doctor)

[The Old Man]

This is handled through a precertification. Ask your insurance company about the process. It is likely an Orthodontist would have to make a statement that the issue could not be fixed through orthodontics alone.

[RealPerson]

... without getting the insurance company's pre-cert in writing first.

On the phone people will say anything. Make sure you have the approval of your insurance company IN WRITING prior to the surgery. Not in general terms but a specific approval for your procedure and how much they will pay. Anything else is utterly useless. Also obtain a written quote from your dentists as to how much it will cost so that you know what you owe them.

There is not much you can do besides some prodding and pushing. Medical billing is a very complicated process. You will need your dentists to do the heavy lifting in that regards. Best of luck.