General Question

Aqua's avatar

What can I do about this dental insurance claim?

Asked by Aqua (2546points) March 27th, 2013

Recently I needed to have a dental procedure done, and the dentist’s office said they would check with my dental insurance provider (Delta Dental) to see if it would be covered. The dentist explicitly told me it would be covered, so I went ahead with the procedure (I could not really afford it otherwise). Now that the procedure has been done, the dentist sent me a bill and informed me that the insurance company denied the claim and I must pay the full amount.

I talked to the secretary at the dentist’s office this morning and she told me that ultimately it’s my responsibility to know what’s covered and that they just do the best they can. She was pretty unsympathetic.

However, the Delta Dental website says, “Dentists who accept Delta Dental will file claims for you. You only need to file a claim when visiting a non-Delta Dental dentist.” I don’t know what I could’ve done since it’s the dentist’s responsibility to file the claim, not mine. What are my options here? Have any of you ever been in a similar situation?

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10 Answers

Judi's avatar

If you can talk to the dentist directly that’s best. At the least he can discount his fee and work out a payment plan, at best he can honor what his staff told you.
Then again, Delta Dental sucks. He could just blow you off and send you to small claims.

chyna's avatar

When the secretary first contacted Delta Dental, they gave her an authorization number (or should have) when they said they would pay for the procedure. Get that authorization number from the dentist and call the claims department giving them that number. They have to honor any preauthorization unless the procedure was more indepth than anticipated, but they still have to pay what they said they would.

livelaughlove21's avatar

It wasn’t your responsibility to file the claim, no, but it’s your responsibility to make sure the particular procedure is covered under your particular plan. Unfortunately, the doctor telling you it’ll be covered isn’t enough. Before any major/expensive visit, you should call the insurance company and verify coverage yourself. That way, if they don’t cover it when they said they would, you can take it up with the insurance company. Sorry, but my guess is that you’re stuck with this bill.

Ask about a potential authorization number as @chyna mentioned, but I know from working in a medical office that not all procedures (or insurance companies, for that matter) require an authorization number, so there may not be one.

Aqua's avatar

Ok, I’ll try to find out if there was an authorization number, and I guess I’ll have to be more careful in the future and less trusting of my dentist.

Tachys's avatar

Don’t give up. I work in insurance. Get a copy of the denial letter. There has to be an appeal procedure. Find out the name of the person who denied the claim and talk to them. There must be a claim number…be sure to reference it on everything. The secret to getting your claim paid is to find out hat information the insurance company is missing and get it.

marinelife's avatar

You can ask your dental insurance company why they would not cover it. You can ask the dentist to lower the amount since you may have to pay yourself and you can ask them the take payments, but you did choose to have the procedure done and you are responsible for the bill.

singysars's avatar

I would also look into what you signed at the office (either when you started there as a patient, any yearly forms, or when you got this procedure done). Usually offices like this will have specific wording about responsibility to pay, insurance claims, and such. The dental office should provide you with copies of any such documents. What you agreed to should ultimately tell you whether you’re on the hook or not (though, sadly, you likely are).

@Tachys also makes a great point point—there is likely something missing on the insurance end. Keep in mind neither the insurance company nor the dental office is nearly as motivated as you to see the claim through. There’s likely something to be done that no one has taken the time to pursue. Did you ask the dental office if they know why the claim was denied? Usually denials come back with some sort of identifying code (lack of preauth, not covered, no referall, etc.) Sometimes the reason is as silly as the bill having been sent with the wrong ICD-9 code on it. I believe there’s a window on how long you have to get this done, but I’m not sure how long (60 days?).

jca's avatar

Please update us when this is resolved (or not resolved) so that we can try to learn from your experience.

Thank you.
The Update Lady

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