Dental Procedure Insurance Not Paying
Don't apologize you're fine. The problem with a lot of people that work for insurance companies is that they seem to accept "the average joe" to know everything about how their plans work. Not that I think you are average in way oh you know what I mean.
Okay regarding the "cheat sheet" you have if I'm understanding you correctly that is for your medical plan correct? Not your dental plan. If I am understanding you correctly then it is only for medical and the reason it doesn't separate Dental into In Network vs, Out of Network is because Medical Plans only cover dental work caused by accidents in which case a person whose been in an accident and requires immediate dental treatment is clearly in no condition to choose which provider they want to see. I ahve a strong feeling your cheat sheet doesn't separate Emergency Services either. Same rationale.
Okay now about what you listed as far as percentages and deductibles are concerned:
Deductible: $50/Individual, $150/Family
Prevent/Diagnost: 100% (no ded.)
Basic & Restorative: 80% (ded)
Major Restor: 50% (ded)
Calendar Yr Max: $2000
(then some unrelated ortho stuff)
Okay so we have determined you can go see any dentist you want. It doesn't matter if they are in or out of network. Them being in or out of network will just determine how much will be paid. Procedure Code D7230 plan pays 80% of the negotiated network fee meaning the doctor's fee is normally $300 for patients with no insurance. But if the doctor is in network both the doctor and the insurance company have agreed that the doctor will only charge patients with this insurance $250. So then the insurance company pays 80% of the $250 not 80% of the $300. Leaving the patient to pay 20% of the $250.
If the doctor is out of network then the plan will only pay up to the maximum allowable amount. Here's the catch to that, because the doctor is not in network and has no contract with the insurance company the insurance company is in no way obligated to tell the doctor what the exact dollar amount is that they will pay. So for exampe purposes lets just say that the doctors regular fee is $300 for this one procedure but the insurance company's maximum allowable for this procedure for out of network doctors is $175. The patient is responsible to pay the difference. The doctor will needed to have submitted a PTE ( Pre Treatment Estimate ) to ensure how much will be paid
All of the above is based upon already meeting your deductible but even then we can easily do the math since your deductibles are nice easy round numbers.
I'm sorry but with all of the info you have given me I hate to be the one to say this but it sounds like the insurance company is jerking you around. I'm sure you have already told me this but what is the exact reason for the denial? Is this the only procedure being denied? If your additional out of pocket cost is $245 and your deductible is only $50/$150 then you would have clearly met your deductible with this one procedure. Basic and restorative services on most plans go towards the deductible which is why I ask if you had any other services completed. Your anethesia is included in basic and restorative so that shouldn't be a problem either.
I know it's a lot of info to take in all at once but I don't mind breaking things down. Hey I saw The Rainmaker.
Don't apologize you're fine. The problem with a lot of people that work for insurance companies is that they seem to accept "the average joe" to know everything about how their plans work. Not that I think you are average in way oh you know what I mean.
Okay regarding the "cheat sheet" you have if I'm understanding you correctly that is for your medical plan correct? Not your dental plan. If I am understanding you correctly then it is only for medical and the reason it doesn't separate Dental into In Network vs, Out of Network is because Medical Plans only cover dental work caused by accidents in which case a person whose been in an accident and requires immediate dental treatment is clearly in no condition to choose which provider they want to see. I ahve a strong feeling your cheat sheet doesn't separate Emergency Services either. Same rationale.
Okay now about what you listed as far as percentages and deductibles are concerned:
Deductible: $50/Individual, $150/Family
Prevent/Diagnost: 100% (no ded.)
Basic & Restorative: 80% (ded)
Major Restor: 50% (ded)
Calendar Yr Max: $2000
(then some unrelated ortho stuff)
Okay so we have determined you can go see any dentist you want. It doesn't matter if they are in or out of network. Them being in or out of network will just determine how much will be paid. Procedure Code D7230 plan pays 80% of the negotiated network fee meaning the doctor's fee is normally $300 for patients with no insurance. But if the doctor is in network both the doctor and the insurance company have agreed that the doctor will only charge patients with this insurance $250. So then the insurance company pays 80% of the $250 not 80% of the $300. Leaving the patient to pay 20% of the $250.
If the doctor is out of network then the plan will only pay up to the maximum allowable amount. Here's the catch to that, because the doctor is not in network and has no contract with the insurance company the insurance company is in no way obligated to tell the doctor what the exact dollar amount is that they will pay. So for exampe purposes lets just say that the doctors regular fee is $300 for this one procedure but the insurance company's maximum allowable for this procedure for out of network doctors is $175. The patient is responsible to pay the difference. The doctor will needed to have submitted a PTE ( Pre Treatment Estimate ) to ensure how much will be paid
All of the above is based upon already meeting your deductible but even then we can easily do the math since your deductibles are nice easy round numbers.
I'm sorry but with all of the info you have given me I hate to be the one to say this but it sounds like the insurance company is jerking you around. I'm sure you have already told me this but what is the exact reason for the denial? Is this the only procedure being denied? If your additional out of pocket cost is $245 and your deductible is only $50/$150 then you would have clearly met your deductible with this one procedure. Basic and restorative services on most plans go towards the deductible which is why I ask if you had any other services completed. Your anethesia is included in basic and restorative so that shouldn't be a problem either.
I know it's a lot of info to take in all at once but I don't mind breaking things down. Hey I saw The Rainmaker.