Health insurance carriers generally pay benefits for medically necessary care and treatment related to the hair, skin and nails. Most, however, automatically deny benefits for oral health care, that is, teeth.
By using our Insurance Tool Kit, you will learn how to get your claims paid by your health insurance carrier for medically necessary care and treatment for teeth, resulting from ectodermal dysplasia, a congenital anomaly.
State Insurance Laws and Congenital Anomalies
State insurance departments are your friend. Contact them first and understand your congenital anomaly law. Ask them for a copy of the statute.
State insurance departments regulate health insurance. Health insurance laws vary by state. Many states have laws in place protecting people with a congenital anomaly from the moment of birth. You can learn about the laws in your state from this list we compiled.Download List of Statutes On Congenital Anomalies By State
They will require that congenital anomaly and birth abnormalities be covered as an injury or sickness under the policy and cover functional repair or restoration of any body part when necessary to achieve normal body functioning. This includes teeth. (They exclude cosmetic procedures only to improve appearance.)
IMPORTANT: If you are covered under a group health insurance plan, the laws that govern is the state that the policy was sold/issued in, which may be different then the state you live in. To find this out, contact your plan administrator.
IMPORTANT: While on phone, ask them to email you a copy of your actual policy. You can’t fight a denial without your policy and what it covers and excludes.
Even with protections in place, claims for teeth are automatically denied.
Self-Insured/Self-Funded Plans and Congenital Anomaly
Large employers typically don’t offer health insurance to their employees through a state-licensed insurance company. Instead, they self insure/self-fund. These employer-sponsored health benefit plans are not subject to state insurance laws. Rather, they come under a Federal law known as the Employee Retirement Income Security Act (ERISA).
Note: if you work for a government entity, state laws may regulate your plan. This is good because state laws offer strong protections. If your Plan is self-funded, many of these plans offer coverage for congenital anomaly. But, just like insured-plans, claims for teeth are auto-denied.
How We Can Help
Download our Insurance Toolkit
This toolkit will walk you through in detail the steps you need to take to make a successful claim. It also includes sample letters, diagnosis codes, a list of insurance companies that have granted dental benefits under medical.Download the Insurance Toolkit
Read Health Insurance Claims and Teeth 101
Follow each step in this blog post to learn what you need to know and do to submit health insurance claims for your dental care.
Contact our office
Our staff and advisers can talk to you about the process, answer questions, provide tips for success and more importantly, listen with a compassionate ear. Advisers are individuals in our NFED community who have been successful in the insurance battle.Contact Us
Request copies of letters from insurance companies
You can request letters approving benefits for specific individuals. We maintain a file of letters submitted by families who have been successful. Learn how to use these letters in the Insurance Tool Kit.
How You Can Help
If you have been successful in your battle, your knowledge and experience could help others. Here are ways you can share your insight.
- Send a copy of your approval letter to the NFED office. We’ll add it to our file of letters to be a resource for others.
- Write and submit your insurance success story so we can share it with our community.
- Volunteer as an insurance adviser. You would talk to individuals who are in the appeal process to provide tips and share your experience.
Insurance Success Stories
For inspiration, read insurance success stories submitted by NFED families.