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  1. #1
    WonderingToo is offline Junior Member
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    dental procedure - insurance not paying

    What is the name of your state? OK

    We pay a seperate premium for our dental insurance, yet both our health and dental are with the same company, through employer. We are free to choose any dentist we want, as our dental insurance is not "PPO'd", unlike our health insurance.

    Went to the dentist for 6 month check up, received a referral to get wisdom tooth extracted (it was already coming through, and was impacting another molar). Dentist refered me to oral surgeon next door. Got the procedure done, then come to find out the insurance company will not cover it, because this oral surgeon is 'out of network' and the amount due is smaller than our deductible for OuN docs.

    We've tried to appeal it for the following reasons:
    1: It was a dental procedure. In fact, our benefits say extraction of (partially) erupted and impacted wisdom teeth (my case) are covered under "basic restorative services" and "basic restorative services" are part of our dental insurance. Since we are free to choose anyone we want for dental procedures, the "in network/out of network" issue is not applicable.
    2: The codes used by the oral surgeon's office are dental codes (according to them), not 'medical' codes.

    They denied our appeal (which consisted of phoning the insurance company, and getting them to review it). We are planning on now appealing it the 'formal' way, by sending them a letter, but before we do so, I would appreciate any feedback you might have.

    Are we right, and should the insurance company cover the 80% (after $50 deductible met)? Or are they right, and can they deny the claim because the oral surgeon was "OoN" (which we don't see as applicable here)?

    Thanks a bunch.
  2. #2
    ecmst12 is offline Senior Member
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    Is it the DENTAL insurance company that is denying the bill, or the health insurance company?
  3. #3
    WonderingToo is offline Junior Member
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    Quote Originally Posted by ecmst12 View Post
    Is it the DENTAL insurance company that is denying the bill, or the health insurance company?
    We have the same insurance company for both our health and dental. When it comes to our health benefits though we are dealing with a PPO, but when it comes to our dental, we are free to pick whomever we want (to do check ups and perform dental procedures), without a change in coverage (so our dental benefits are not tied to a PPO).

    I hope I am explaining this correctly. Thanks.
  4. #4
    gianna06 is offline Junior Member
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    Wondering Too

    Hi there okay you are saying that your Dental Plan is not a PPO, then is it an DHMO? If it is a DHMO then you have no out of network benefits. Do you happen to know if you have an Indemnity plan? If you do, then you will have some out of network benefits but of course the percentages that the insurance company will be considerably less than compared to IN Network benefits. Do you happen to know what procedure codes the dentist or rather the oral surgeon used when they filed the claim? If not find out. The insurance company is required to tell you as well as the practitioner's office. Do you have a copy of the EOB (explanation of benefits)? What denial code is listed? I'm sorry for so many questions but I need more information to be able to give you answers that hopefully will help.

    I need the following:
    Date of Service: example 06/01/07
    Dates of Coverage example 01/01/07-12/31/07
    Procedure Code: example D0301
    What type of plan do you have: example DHMO, PPO, EPO, Indeminty, Discount

    This is the most important part and I know this is probably going to really leave a bad taste in your mouth.

    While the practitioner may be participating with your insurance company according their Prac ID or Tax ID, they have to be credentialed with the insurance company for every single location they provide services at. For instance lets say you go see Dr. Smith who accepts your insurance. You go to see him at 123 West Ave. But Dr Smith is only credentialed with your insurance company for locations at 456 West Ave and 789 West Ave. Then guess what? The services your eceived are considered out of network and will either be denied in whole or paid based upon your out of network benefits.

    The thing about all of that is; is that practitioner's know this and in good practice they should be advising their patients of this. It would only make sense you know so that way they can ensure payment of the claim.

    I don't know if I can ask this question on here or if you are even allowed to say but who is your insurance company with?
  5. #5
    WonderingToo is offline Junior Member
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    Ok, a lot of things you're asking could easily identify me if you happen to be with our insurance company or employer, and since you are brand new member, I am not too comfortable disclosing all this info to you, but I can give you this.

    We've had the same insurance company for years (name changed once because of merger). Our benefits changed a couple of years ago, from mostly 100% coverage, to 80%. However, our DENTAL benefits never changed. Date of service falls within dates of coverage, coverage is ongoing.

    I understand why the insurance co. is denying the claim - they are considering my oral surgery as a medical procedure, and because medical procedures fall into our PPO, and since the oral surgeon is out of network, they are denying the claim**contributing' it to my individual non PPO deductible $500 out of network deductible (the procedure was $245). The oral surgeon is also a maxillofacial surgeon.

    The reason we disagree with them not paying the claim is that according to our dental insurance, "Simple and erupted tooth extractions" are cover under "Basic Services", under "Dental Benefits". As far as dental benefits/procedures go, we are allowed to pick anyone (assuming that they are licensed to practice, etc.) to perform these procedures.
    It should not matter (in our opinion?) if the doc was in or out of network (health insurance wise), because the procedure was a dental one (EOB says 07230/) and should be considered as such.

    I know legally this doesn't mean a thing, but the oral surgeon's office on the day of the procedure, and AFTER talking on the phone with our insurance company, charged us $50 plus 20% of the total amount due (which is what we owe them according to our DENTAL benefits). Of course now they're charging us the remainder, which we are about to pay since the insurance company is not, but we would like to get the money (back) from our insurance company).
  6. #6
    gianna06 is offline Junior Member
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    dental procedure - insurance not paying

    Fair enough. I don't blame you I would feel the same way.

    But none the less, lets move on.

    Okay this is what you need to do then, If the insurance company is denying your claim because they think that the procedure was a medical procedure then you can either have your provider's office resubmit the claim with a copy of the EOB and a narrative. The provider's office will know what a narrative is. ( It's basically an explanation as to why the procedure was necessary ) If the provider's office has done that already and it is still being denied ( doesn't sound like they have though ) then you will need to submit the claim to your medical insurance.

    Also I think some of the confusion is coming from the fact that you keep talking about your medical plan because it happens to be with the same insurance company Plus you keep referring to your PPO. Maybe I'm just not understanding what you mean.

    PPO - Preferred Provider Organization - you can utilize in or out of network benefits. In Network benefits always pay more than Out of Network Benefits. You can choose any provider without any referrals.

    DHMO - Dental Health Maintenance Organization - you have to be a assigned to a Dentist . You can pick any dentist to be assigned to provided he/she is on the list. You have no out of network benefits.

    With that being said, do you have a DHMO Plan or a PPO Plan for your Dental coverage?

    P.S.
    I work for the largest insurance company literally in the world now due to all of the recent mergers and acquisitions. So you most probably have your Dental coverage with this particular company and I have to be honest I am not at all familiar with the procedure code that you referenced. I will say this all of our procedure codes begin with the letter "D". Which the ADA Procedure Codes are universal meaning that all Dental insurance carriers will use them. So if your provider filed the claim with that other number then No they didn't file it as a Dental Procedure and they need to. I'm sorry I'm not familiar with Medical Procedure Codes but I'm going to have to say that the Code you provided is a medical procedure Code.

    You can refer to this Website for a complete list of ADA Dental Codes and their Descriptions.

    [url]http://www.healthplex.com/Procedures/adacodehelp.htm[/url]

    Hope this helps.
  7. #7
    ecmst12 is offline Senior Member
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    OP clearly understands his benefits, which is more then you can say for most people.

    However, you did not think to call your insurance company and find out if there was anything special that needed to be done to get this covered. Wisdom tooth extractions are sometimes considered medical procedures. Where was it performed? What kind of anesthesia did you receive? When you called your insurance company to ask them about this, what did they say?
  8. #8
    WonderingToo is offline Junior Member
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    Sorry this is long and I probably repeat myself constantly...

    DHMO - I have honestly never heard of that before. We were just told by the insurance company (and have been told the same thing for years) that we could pick any dentist we want. We've never had any problems before. Nor did we ever have a 'list' to pick from.As far as our ins. company: "Our insurance company is "the country's largest independent provider of services for self-funded health plans and serves over 1,400 employer groups and over a million members nationally."

    ECMST: I'm a 'she' Anyways, no - my fault - I should have contacted my insurance co. before the procedure. I assumed that because it was a dental procedure, I would be fine. I was also referred by my dentist (we just moved to the area, so it was a new dentist to me) and didn't think anything was 'wrong' either when the oral surgeon's office told me they had called our insurance and charged me what I expected to be charged at the time of my visit.

    Surgery was performed at the oral surg. office, I had a local anesthetic. Called the dentist office again, code used was D7230 (my EOB states 07230). My tooth was partially erupted and partially impacted. Lady at the dentist office just told me that SOME insurance companies consider partially impacted as completely impacted and therefore consider it medical. I have not read anywhere in my policy that my ins. co. is treating it as completely inmpacted, nor has our ins. company related that to us.

    In fact, I am looking at the 75 pages stating our benefits and under "Class B Services - Basic Dental Procedures" one of the bullets is "Oral Surgery - Oral surgery is limited to removal of teeth, preparation of the mouth for dentures, and removal of tooth-generated cysts of less than 1/4 inch." Another bullet states: "Extractions, simple and erupted. This service includes local anesthesia and post-operative care." Another bullet reads: "removal of partially or unerupted teeth." What does 'simple' mean? Does that exclude partially impacted?

    Prior to a procedure of $300 (mine was 245), the ins company needs to be notified/predetermination of benefits is required, so that is not applicable here.

    I might have used the wrong terms earlier. The ins. company never 'denied' the claim, but instead treated it as out of network, and because the amount due is less then my oon deductible, they applied it to my deductible, leaving me with the bill.

    Insurance has been telling us the same thing: that the oral surgeon is out of network (which he is for health/medical procedures, but again, I believe this was a dental procedure and for those we are not 'bound' to a network'). They are not mentioning the nature of the procedure (say it's supposed to be medical because it was partially impacted? - they have not mention that as a reason to us).

    So what should my next step be? The procedure was in January, and the ins. company has taken their sweet time to deny it the 2nd time (after we phoned them to review it).
    We have 180 days to appeal claim - assuming day 1 is day of procedure, we're getting closer.

    I am thinking of writing a formal letter (ideas/templates?) and basically stating what I am stating to you above (referring our benefits). Asked the dental office to refile it with 'narrative' and was told that a narrative is 'attached' to the dental code used and the insurance company (or their computer system) should recognize that?

    Thanks for both your time and input.
    Last edited by WonderingToo; 05-02-2008 at 11:41 AM.
  9. #9
    WonderingToo is offline Junior Member
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    Update/even more info (sorry),

    husband called insurance company, the following is a 'result' from that.

    Our benefits are drawn up by my husband's employer, as in they decided what gets covered and how. According to the cust. service person at the insurance company, it seems like they have created some sort of 'loophole' when it comes to the extraction of wisdom teeth.

    While all the above is true (in my previous post I stated what was covered by dental benefits), one of the dental benefits exlusions states: "Medical services: Services that to any extent, are payable under any Medical Expense benefit in the Plan."

    Under our Medical Benefits, "Other Medical Services and Supplies" it has a 'bullet': "Injury to or care of mouth, teeth, and gums. Charges for injury to or care of the mouth, teeth, gums and alveolar processes will be covered charges under medical benefits only if that care is for the following oral surgergical procedures." One of the things listed is "Removal of partially erupted or unerupted teeth"

    There is no mention anywhere of 'impacted'. This same "removal of partially erupted or unerupted teeth" is also part of our dental benefits. Seems like a loophole to me.

    Why would that be listed on both? I understand the insurance company putting it to our deductible for OON, because of the the reading in the medical benefits now, - I mean, they're out less (none) money. But since it is also in our dental benefits, and does not make a reference to the medical benefits, do we 'have a case' to get them to process it under dental?
  10. #10
    ecmst12 is offline Senior Member
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    I think the "partially impacted" is what's making it medical. "Partially impacted" extractions would not be considered "simple" I don't think.
  11. #11
    WonderingToo is offline Junior Member
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    Quote Originally Posted by ecmst12 View Post
    I think the "partially impacted" is what's making it medical. "Partially impacted" extractions would not be considered "simple" I don't think.
    Ugh, that is what I am starting to think too, but...

    1. there is no mention in our benefits of anything 'impacted' related to teeth.
    2. not all the 'inclusions' in the dental benefits state the extractions need to be simple
    3. the insurance comp has never mentioned that to be the reason for 'denial' or for it to be considered medical.

    It was a 2 minute tops procedure, what's not 'simple' about that :P
  12. #12
    ecmst12 is offline Senior Member
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    You can try to file an appeal to have it considered dental instead of medical since it seems, on the surface, to fit the criteria.
  13. #13
    gianna06 is offline Junior Member
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    Insurance not paying claim

    Okay, wow you have a lot of information here. Okay lets start from the beginning.

    What the customer service rep advised your husband is partially correct. This is honestly how it works. A sales agent working for the insurance company goes out to literally hundreds of potential clients ( Walmart, Home Depot, Lowe's, PlayBoy, you name it )and tries to sell the plans. The insurance company offers literally thousands of plans that a potential client can choose from. Remember when I say Client I mean the Benefits Adminstrator of the Company/HR Department/Whomever is responsible for Employee Benefits. Now keep in mind the Client is still responsible for paying a portion of the premium so that their employees aren't responsible for the whole cost. A lot of employers offer "company paid benefits" well that is what they are talking about. Or they say that you are getting discounted premiums. Ever notice on a pay stub or W-2 where it says employers cost for benefits. Okay so lets say the Insurance company offers three plans and the premiums are as followed $300 biweekly per employee, $200 biweekly per employee, $100 biweekly per employer. The lesser premium of course offers the least amount of coverage. If the employer has lets say 1,000 employees and they pay lets say 25% of the premium so their employees only have to pay 75% of the premium. Which plan do you think the employer is going to opt for?

    So when the customer service rep said that your husband's employer sets the guidelines for the plan what they really should have said is, this is the plan that your husband's employer has selected for it's employees.

    All of that is really behind the scenes stuff.

    Next, okay so the Procedure Code is definitely a Dental Procedure however if I'm unsderstanding you correctly. The claim is being denied because the oral surgeon is not in network with the insurance company. If this is correct then you don't have a PPO Plan you have a DHMO Plan. With DHMO Plans you are only allowed to see In Network Providers/Participating providers. Therefore your claim was denied correctly.

    Let me ask you this and please set aside your medical plan information because it really has no baring on your dental plan. When you go into the dentist, do you pay a copay or do you pay a coinsurance.

    Medical Plans will pay for some dental procedures depending on the cause for dental work. If someone gets into a car accident and breaks their jaw and loses teeth then that is considered medical. Or if someone is assaulted and again loses teeth this is considered medical. ( However anytime anyone is a victim of assault they are never responsible for any medical costs )

    Let me know.
  14. #14
    WonderingToo is offline Junior Member
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    Thanks for your informational reply. I appreciate it, however, I disagree with your statement that we have a DHMO plan that only allows us to see in network dentists. That term has never been used in the many years we've had this dental insurance, it is not described in our benefits/policy package, has never been used by the insurance or my husband's employer, and our insurance company has repeatedly told us we can see any dentist we want to, we don't even have to check with them (insurance company), just have the dentist send in the bill, and it will be covered according to our dental benefits.

    As far as whether we have co-pay or coinsurance, hope this helps:

    Dental

    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)

    I know you don't like me bringing up the medical/health part, but I do think it is relevant since it's the only way to explain (somewhat?) the ins. co. thinking, and also explains my first paragraph.

    We have a little 'cheatsheet' sorta say, that outlines/summarizes our benefits on one page. In the left column are headings such as "welness, major medical, hospital benefits," etc. One of those headings is "dental". In the right column, it states what our benefits are concerning these. That right column is divided in 2, displaying in-network benefits per heading on one side, and displaying the out of network benefits on the other side.

    However, when it comes to the "dental" heading, the second column is not split in 2 parts, but the benefits are listed in the middle of that column, so neither under INN, or OON, meaning those benefits are not 'network-bound'.

    Sorry this is taking so long and so many posts Thanks so much for both of your feedback though!)

    (not sure if this helps, but the premium for our dental insurance is taken out of my husband's paycheck seperately)
  15. #15
    WonderingToo is offline Junior Member
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    Quote Originally Posted by ecmst12 View Post
    You can try to file an appeal to have it considered dental instead of medical since it seems, on the surface, to fit the criteria.
    Thanks, I think that's what we're going to do, it's worth a try either way. Would it be ok if we paid the oral surgeon the remainder of the balance? They have been waiting for the $, and sending us statements, but because we are in constant touch with them and they know about this insurance thing, they are being patient and understanding. I have offered to pay the remainder so they at least get paid, and that if the ins. co decides to reverse the decision, they can pay us back directly (or the oral surgeons, who's office can then in turn reimburse us), but they have said we don't have to as long as we're trying to figure this out with the ins. co.

    Would paying the oral surgeon's office be an admission to our insurance company that we agree with their (ins. co) decision? Keep in mind we have no problem paying the oral surgeon.

    Thanks!

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