Insurance Verification Form

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At TMJ & Sleep Therapy Centre of North Texas we understand that navigating insurance can be difficult and overwhelming. Know what questions to ask when calling your insurance company by utilizing the form.

Date
Time
Representative Name
Call Reference #:
What is my deductible?
How much has been met?
Is this plan a PPO that allows me to choose my doctor or am I bound to go to in network doctors only?
Can I have a gap exception? Dr. Krish is a non-participating provider, as she is a Periodontist that is Board Certified in TMJ and Sleep but not an MD.
*Please note that EPO plans or HMO plans will need a referral from a PCP before an attempt can be made to get a gap exception.
Do I have any benefits for undiagnosed head and facial pain?
Are there any exclusions or limitations in the plan for craniomandibular orthopedic treatments as needed for my condition?
Are there any limitations or exclusions that would prevent me from having benefits for treatments for the temporomandibular joint? (this is for the appliances or DME equipment) If I have an exclusion for the TMJ Joint, can I have a copy sent to me?
What criteria must be met for DME (Durable Medical Equipment)?

Codes that could possibly be used as part of treatment:

99204 New Patient Comprehensive Exam
70355 Panoramic
76102 Bilateral Sagittal TMJ Tomogram
70250 Submental Vertex
D7880 or E1399Mandibular Orthopedic Repositioning TMJ Appliance
E0486 Lab Processed OSA Appliance