Insurance Claim Forms

At our practice, we prioritize transparency and personalized care. As a direct pay provider, we do not bill insurance directly, but we offer several services to help you navigate your insurance benefits. Here’s how we can assist you: 

1. Insurance Verification for Out-of-Network Reimbursement 

We can help you check if your insurance plan covers services from out-of-network providers like us. If you have out-of-network benefits, this allows you to submit a claim to your insurance for potential reimbursement. 

  • What We Do: We verify your insurance benefits and provide an estimate of what your plan might cover. 

  • What You Do: Pay for the procedure upfront and then file for reimbursement. 

2. Insurance Claim Submission Assistance 

Even though you’ll pay us directly, we can assist with submitting your claim to your insurance company. 

  • What We Do: After your procedure, we’ll give you a detailed, itemized bill with all the required codes (CPT and ICD codes) and proof of payment. If needed, we can submit the claim on your behalf. 

  • What You Do: Once the claim is processed, any reimbursement will be sent directly to you. 

3. Gap Exception Requests 

If your insurance company won’t cover out-of-network providers, we can help you request a gap exception. This exception treats us as an in-network provider if no in-network providers are available for your surgery. 

  • What We Do: We help you gather the required documents, such as a letter from your referring doctor or proof that no in-network providers are available for your procedure. 

  • What You Do: Submit the gap exception request to your insurance company and await approval. 

How the Payment Process Works 

Regardless of your insurance coverage, payment for all procedures is due upfront on the day of your appointment. Once your insurance claim is processed (with our help), any reimbursement will go directly to you. 

Provider Information for Insurance Claims

When submitting your claim, you may need the following information:

Dr. Patrick Kline
Central WI Oral & Facial Surgery
311 Financial Way, Suite 230
Wausau, WI 54401
NPI #: 1154422848
Tax ID #: 82-1908740

Medical Claim Form
Dental Claim Form