Gap Exception with Sleep Apnea Insurance Billing for Dentist

Now, more and more dental practices are choosing to offer treatment for sleep apnea due to the use of an oral appliance. However, this does create a certain set of challenges as the patient’s medical coverage must be billed instead of their dental. With sleep apnea insurance billing for dentist treatments, one area you may have difficulty with is a gap exception. At Brady Billing, we understand the process is a bit confusing. We will help shed some light on the insurance waiver.

What is a Gap Exception?

A clinical gap exception is a tool used by health insurance companies to compensate their network of health care providers that they have contracted. Essentially, it allows a patient to see an out-of-network provider when there is not one in-network to provide the necessary treatment. While the provider is not within their network, the insurance company will accept in-network cost sharing fees due to the gap in coverage. This offers a more affordable option for treatment than what would typically be found when seeing an out-of-network dentist.

How Can a Gap Exception be Used?

To be reimbursed fully by the insurance company, the patient must first be approved for a network gap exception during the process for sleep apnea medical billing for dentist. By requesting the coverage, they formally ask their provider to cover their out-of-network treatment at a lower rate. If the insurer approves the request, then the patient will pay the in-network cost for the deductible, co-pay, and coinsurance.

While this waiver is there to help patients who cannot find an in-network provider for the treatment, most insurance companies are not too eager to approve the request. This is where the challenge develops. Since it will involve extra work and added expense on the insurer’s part, you must make sure the process is conducted correctly to promote the approval of the request.

How Can I Get a Gap Exception Approved?

To help ensure the insurance company will not reject the waiver, the treatment that is being requested must be medically necessary and a covered benefit. In addition, there cannot be an in-network provider who is capable of performing the treatment within a reasonable difference. Depending on the insurance company, this may include 50 miles; however, some will have a longer or shorter distance requirement.

The request for coverage must be submitted prior to providing the treatment. If it is done afterward, the insurance company will process it as an out-of-network claim. When submitting the request, there are several pieces of information that are required, such as the CPT or HCPCS codes, ICD-9 or ICD-10 codes, and a list of any in-network providers. If the correct information is not submitted, it will lead to costly delays.

Can I Get Help with Gap Exceptions?

Submitting the information for coverage can be quite the hassle. At Brady Billing, we simplify the process. We will handle and submit the necessary paperwork while negotiating with the insurance company. Contact us today for a stress-free process.