Financial coverage options for OMT in Canada
1. Dental insurance benefits
Although it is rare for dental insurance to cover OMT treatment, it is at times covered by plans that offer benefits beyond basic level coverage. More commonly, codes that are not specific to myofunctional therapy such as photo records or a consultation may be covered.
2. Speech language pathology coverage
For this type of coverage, the treatment would need to be performed by a speech language therapy office that provides myofunctional therapy as a service.
3. Canada Dental Benefit – New as of Dec 2022
If the patient is under age 12, your family has an annual adjusted net income that is less than $90,000, and you do not have private dental insurance, you may be eligible for the “Canada Dental Benefit”, which can cover any oral health services provided by any oral health professional, including dental hygienists.
Claiming dental insurance coverage
At our office we do not provide direct billing. Patients must pay up front for treatment and can submit their receipts to their insurance company for reimbursement. The receipts from our office come printed with the dental hygienist’s UIN (unique identification number) on them and the procedure codes. If you also require a claim form, we can provide this to you upon request so that you can submit it to your dental insurance company.
Pre-determination of coverage
To determine if there is coverage for treatment through a dental insurance company, you can simply call them and ask if the following codes in the far left column are a benefit on your plan.
|Code||Item (u = unit of 15 mins of time)|
|05001||Examination and Diagnosis: Stomatognathic, Dysfunctional, Comprehensive|
|00279||Additional photo over 3|
|00922||2u Professional Communications/Case Presentation|
|00921||1u Case Presentation/Treatment Planning (Client, family, and members of the health care team)|
|05004||Orofacial Myofunctional Therapy Examination: Reassessment Previous Client|
|05011||1u Orofacial Myofunctional Therapy|
|05012||2u Orofacial Myofunctional Therapy|
Alternatively, we can send a paper pre-authorization on your behalf. Please note that it often takes about 1 month to hear a reply. Most insurance companies send a reply within the patient’s online account so please check your account if you are wondering about a response. In the rare chance that we receive a letter from your insurance company at our office, we will contact you.
Troubleshooting denied pre-authorization & claims
The codes we use at Pearl OMT & Dental Hygiene are dental hygiene codes rather than dental (or a dentist’s) codes because Pearl OMT is an independent dental hygiene practice. This means the practice is owned and operated by a DHP or dental hygiene practitioner. That said, most codes in the dental hygiene fee guide are mirrored in the dentist’s fee guide. “2u Orofacial Myofunctional Therapy” would be billed with code 05012 by us or code 14312 in the case of a dentist or dental practice. It’s the same procedure, just a different code.
If you are having a problem with your insurance company recognizing the codes, it could be one of the following problems:
1. The procedure is not a benefit on your dental plan.
2. The dental insurance company staff member helping you is in a province where independent dental hygiene practices do not exist and the insurance company has done a poor job at educating their staff that this exists in other provinces in Canada.
3. The dental insurance company is not up-to-date on adding dental hygiene codes into their database.
If you were able to confirm that myofunctional therapy is a benefit of your dental insurance plan but they will not cover the codes billed by Pearl OMT, we are very happy to advocate for you and try to speak to someone in higher authority within your insurance company. This allows us to advocate for other patients with the same insurance company in the future.