We Accept Most Medical Insurance Plans

We are committed to transparent billing practices, with clear communication of treatment costs, insurance expectations, and patient responsibilities so you can make informed decisions about your care.

TMJ / Orofacial Pain and Sleep Apnea conditions are considered medical conditions rather than dental conditions. As a result, dental insurance typically does not cover TMJ services, and our clinic bills medical insurance only.

We are currently in-network with Medicare, Premera, Blue Cross Blue Shield National PPO (excluding Regence, FEP), LifeWise, First Choice Health, Cigna, WA Labor & Industries (Workers Comp) and Aetna.
Starting 05/15/2026, we will be in-network with Kaiser HMO.

For all other plans, we are considered out-of-network. If your plan includes out-of-network benefits, we may submit claims on your behalf as a courtesy or provide a superbill for self-submission.

In some cases, we may request a gap exception (single-case agreement). Approval is determined solely by your insurance company and is not guaranteed. If approved, services will be billed per the agreed terms; if not, services will be billed according to your out-of-network or self-pay benefits. Gap exceptions may not be available for Regence, Medicare, or Medicaid.

What to Know About Insurance Coverage for TMJ services?

Insurance coverage for TMJ and orofacial pain treatment varies widely and can be complex, depending on your individual plan.

We make every effort to obtain benefits information from your insurance company and provide you with an estimate; however, this is not a guarantee of coverage or payment.
Your insurance company—not our office—determines coverage, medical necessity, and claim payment. These decisions are made during claim processing, after services have been rendered and claims have been submitted.
Prior authorization from your insurance company does not guarantee claim approval or payment.
During claim processing, services may be denied regardless of prior authorization status.
Your insurance company also determines your financial responsibility, including deductibles, co-insurance, and non-covered services.

Our provider determines medical necessity based on clinical evaluation; however, your insurance company may apply different criteria when reviewing claims.

We strongly encourage you to contact your insurance carrier directly to understand your specific benefits, coverage, exclusions, and limitations. Information regarding CPT codes billed are always provided to you prior to the visits.

What to Know About Insurance Coverage for Sleep Apnea Oral Appliance Therapy (OAT / MAD)?

Insurance coverage for sleep apnea treatment with oral appliances (mandibular advancement devices) varies widely and can be complex, depending on your individual medical insurance plan.

We make every effort to obtain benefits information from your insurance company and provide you with an estimate; however, this is not a guarantee of coverage or payment.
Sleep apnea treatment with an oral appliance is typically considered a medically necessary treatment when prescribed for obstructive sleep apnea (OSA) by a qualified physician (such as a Sleep Specialist, ENT, or Medical Doctor) based on a sleep study.
However, we do not diagnose sleep apnea. This diagnosis must be made by a qualified medical provider and is outside the scope of our practice.
Your insurance company—not our office—determines coverage, medical necessity, and claim payment. These decisions are made during claim processing, after services have been rendered and claims have been submitted.
Prior authorization from your insurance company does not guarantee claim approval or payment.
During claim processing, services related to oral appliance therapy—including the device, adjustments, and follow-up care—may be denied regardless of prior authorization status.
Your insurance company determines your financial responsibility, including deductibles, co-insurance, and non-covered services.

Our provider determines clinical appropriateness and fabricates the oral appliance based on clinical evaluation; however, your insurance company may apply additional criteria when reviewing claims.

These include requirements such as:

A documented diagnosis of obstructive sleep apnea based on a sleep study
A prescription from a qualified medical provider to fabricate a Mandibular Advancement Device (MAD)
Documentation of CPAP intolerance or preference (depending on the plan)
Use of a qualified, custom-fabricated device (e.g., HCPCS code E0486)

We work closely with a team of board-certified sleep specialists to coordinate care, facilitate required documentation, and support a smoother and more efficient treatment process.

We strongly encourage you to contact your insurance carrier directly to understand your specific benefits, coverage, exclusions, and limitations. Information regarding applicable CPT/HCPCS codes is provided to you prior to treatment when available.

How We Navigate Claim Denials

Claim denials by insurance carriers are uncommon in our practice; however, they can occur.

Our process is robust and proactive:

We submit claims with detailed documentation supporting medical necessity.
If a claim is denied, we work with an experienced billing team to review and appeal when appropriate.
Appeals may include additional clinical records and supporting documentation and may require additional authorization or input from the patient.
We keep you informed of claim status and updates throughout the process.

This approach is consistent with how insurance claims are managed across many healthcare practices in the United States.

While denials are uncommon, they may occur. In such situations, patients may understandably feel frustrated. In some cases, patients may believe that the information provided by the practice created expectations regarding insurance coverage prior to a visit or treatment.

However, it is important to understand that while we make every effort to provide accurate information based on details received from your insurance company, coverage for services is ultimately determined by your individual plan during claim processing (after services are rendered), whether at our office or any other healthcare provider.

Most denials are based on plan-specific coverage policies rather than lack of medical necessity. In some cases, claims may remain denied even after multiple appeals due to factors beyond the control of both the provider/clinic and the patient. In such circumstances, any outstanding balance for services rendered will become the patient’s financial responsibility.

Patient Responsibility

While we are committed to supporting you through the complexities of insurance and billing, patients are ultimately responsible for understanding their coverage and financial obligations.

You, as a patient need to:

Verify your benefits, coverage, and exclusions with your insurance company prior to receiving services.
Understand that all insurance coverage determinations are made solely by your insurance company, not by any provider/ practice/ hospital.
Remain financially responsible for any portion of the balance not covered or denied by insurance, including deductibles, coinsurance, and non-covered services.
Respond promptly to requests from our office or billing team regarding your claims, as delays in response may result in delays or denials in claim processing.

Non-Covered Services

If a service is clearly identified as non-covered under your plan, we may elect not to submit a claim to avoid unnecessary delays or denials. This will be discussed with you prior to your appointment. In such cases, services will be provided on a self-pay basis at discounted rates, and full payment is due at the time of service.

Payment Policy

We are contractually obligated to honor in-network allowable amounts for covered services only, when applicable. However, all fees are due at the time of service based on your estimated patient responsibility unless prior arrangements have been made.

Co-payments, deductibles, and co-insurance are collected based on your estimated responsibility. These estimates are not guarantees.

After claim processing:

Any remaining balance as determined by your insurance will be billed to you
Any overpayment will be refunded, usually by check

Payment Options

We accept credit and debit cards and offer financing through Cherry, along with in-office payment plans. Many services are eligible for HSA and FSA use.

Questions?

If you have questions about your insurance, reimbursement, or payment options, please contact our office at (206) 880-0119 or email us info@advancedtmjsleep.com

Please check this page periodically for updates as insurance participation may change.

Still unsure about your next steps?

We understand that navigating insurance and billing can be complex, and choosing the right provider is an important decision.

While we are help to help you navigate this complexity, if you prefer to have a detailed understanding of your specific benefits, coverage, and out-of-pocket costs prior to scheduling, we strongly encourage you to contact your insurance carrier directly.

We also recognize that different patients have different preferences when it comes to insurance participation and financial expectations. You may also explore your insurance provider’s directory to find an in-network provider whose approach best aligns with your preferences.

Last Updated: 4/26/2026