Chief complaint

—

Working diagnosis

Recommended treatment

Fees shown are full Usual, Customary & Reasonable (UCR) charges. Actual patient responsibility depends on your medical plan, deductible, and any balance-billing rules.

Clinical notes

What to do

1. Call the member services phone number on the back of your medical insurance card.
2. Tell them: "I am calling to verify medical benefits for treatment of a temporomandibular disorder (TMD) / orofacial pain condition. My provider is out-of-network."
3. Read them the diagnosis and procedure codes below, then work through the questions list.
4. Write the answers on the return form and bring it back to our office.

Codes to read to the representative

Questions to ask — general

1. Is treatment for temporomandibular joint disorder (TMD) a covered medical benefit under this plan? Are there any plan exclusions for TMD?
2. What are my out-of-network medical benefits? Deductible, coinsurance, and out-of-pocket max?
3. How much of my out-of-network deductible has been met for this calendar year?
4. Is prior authorization required for any of the codes I just read? If yes, which ones and what is the process?
5. Is a medical referral or gatekeeper approval required from my primary care physician?
6. How do I submit an out-of-network claim for reimbursement, and where do I send it?
7. Reference / call number for this call: ____________________    Representative name: ____________________

Questions to ask — for each procedure code above

Please bring back the following before we begin treatment

• Front and back copy of medical insurance card (photo or physical)
• Government-issued photo ID
• Prescription / referral from PCP or ENT (if plan requires it)
• Recent sleep study report — required if E0486 oral appliance is part of plan
• Any prior imaging (CBCT, MRI, panoramic) related to jaw / face pain
• Completed medical history and TMD symptom questionnaire
• List of current medications
• Prior TMD or oral appliance treatment records (if applicable)
• Signed Assignment of Benefits / Financial Policy (provided at check-in)
• Signed HIPAA release if we need to speak with another provider on your behalf

Front-desk verification (staff use)

Working diagnosis

Treatment we will provide and bill

How your medical insurance will be billed

Atlanta Center for TMJ will submit claims to your medical insurance carrier on your behalf using the codes above. Because we are out-of-network, payment amounts are determined by your carrier and are not guaranteed. You are financially responsible for any deductible, coinsurance, non-covered services, and any balance not paid by your carrier.

You authorize us to release medical information necessary to process your claim and assign benefits directly to Atlanta Center for TMJ.

Patient acknowledgment

• I have reviewed the diagnosis, the recommended treatment, and the full UCR fees above.
• I understand my insurance plan may pay less than the full UCR amount, and I am responsible for the balance.
• I authorize Atlanta Center for TMJ to submit medical claims on my behalf and to receive payment directly.
• I agree to bring back the documents on the checklist page before treatment begins.