Claiming for wisdom teeth removal
Has your healthcare provider recommended that your wisdom teeth are removed? Whether your teeth are removed at the dentist or in hospital, together with your level of cover, will determine what you can claim with your health insurance and any possible out-of-pocket costs you may have.
We’ve put together an easy-to-follow guide and some frequently asked questions to explain how wisdom teeth removal is claimed with private health insurance.
What are the waiting periods for wisdom teeth removal?
If you’re new to health insurance or didn’t have prior cover for wisdom teeth removal, there is a two-month waiting period for the teeth extraction, and a two-month waiting period for any inpatient hospital services (i.e. accommodation, theatre fees and anaesthetist), unless the condition is pre-existing, in which case a 12-month waiting period will apply. (Click here for more information on pre-existing conditions)
You only need to wait two months for the extraction because it is a general dental service covered by extras cover. This is regardless of whether your teeth are removed in hospital by a surgeon or at the dentist.
If your teeth are removed in a dental surgery, additional services such as the administration of anaesthesia or sedation can receive a fixed benefit under extras cover. These services therefore have a two-month waiting period.
How does wisdom teeth removal differ to other in hospital (inpatient) procedures?
The biggest difference between wisdom teeth removal and other inpatient procedures is that the costs charged by your surgeon are claimed under extras cover, even though the services are performed in a hospital. On Total Extras and Essential Extras, a fixed benefit is paid per tooth removed, up to your general dental annual limit. Starter Extras doesn’t include benefits for oral surgery.
This means if you only have hospital cover, you can claim for hospital services such as your accommodation, theatre fees and anaesthetist. But you will be unable to claim anything back for your surgeon’s costs.
Why aren’t the services by my oral or maxillofacial surgeon covered by my hospital policy?
This is because the Medicare Benefits Schedule (MBS) doesn’t pay benefits towards the extraction of teeth in hospital. To allow for patients to claim something back with extras, oral and maxillofacial surgeons bill their services according to the Australian Schedule of Dental Services and Glossary. Common item numbers for wisdom teeth removal under this schedule include 322 and 324.
If you have your wisdom teeth removed by your dentist, they will use the same billing process for their services.
Can I choose whether to get my teeth removed in hospital or in a dental surgery?
This is a decision that needs to be made in consultation with your healthcare providers. It is often determined by the complexity of your treatment and whether the removal can be performed by a dentist or surgeon.
How do I find out how much I’ll get back?
After speaking with your dentist or surgeon, call our Member Services team to discuss your upcoming procedure. Tell us the item numbers your dentist or surgeon has provided to you, and we can advise on any waiting periods and the benefits you can expect to get back.
Always check we have an agreement with your preferred hospital, which you can do online here, or during your phone call with us. If we don’t have an agreement, you are more likely to have significant out-of-pocket costs.
How do I make a claim?
To claim extras benefits (so your surgeon’s or dentist’s invoice), submit a photo of your receipt through the app and we’ll get your benefits processed and paid to you in the business days that follow.
In most cases, we will receive the invoices for your hospital stay directly from the hospital and anaesthetist. If applicable, you will pay any out-of-pocket costs to these providers separately.
Private health insurance products are issued by The Doctors’ Health Fund Pty Limited, ABN 68 001 417 527 (Doctors’ Health Fund), a member of the Avant Mutual Group. Cover is subject to the terms and conditions (including waiting periods, limitations and exclusions) of the individual policy, available at doctorshealthfund.com.au/our-cover.
