Dental & Medical Coverage Denied

[sturgbe]

Hello All,

I have a question about coverage being denied for both Dental & Medical insurance. The person in question has coverage through their employer: Guardian dental (PDO) and Blue Cross-Anthem of CA.

She went in due to an infection in the jaw. The oral surgeon had to remove two teeth to remove the infection. She also had a root canal.

Dental has denied all coverage and so has BC. I asked her to get some the SPD of her coverages and all bills together. Any thought or advice on how to proceed to get at least something covered.

TY All,

 

[dgoldenz]

First question would by why the charges were denied...

 

[DS4]

First question would by why the charges were denied...

Ditto.


Probably a claim "coding" issue with the dentist office.
Of the entire claim, part was probably dental, and, part medical???
If so, probably need to separate the billing.

 

[Ann H]

In addition to getting the SPD, also get the EOB (explanation of benefits) from both carriers, explaining the determinations that they made on the claim.

This sounds more like dental than medical.

Medical plans sometimes pay for accidental injury to sound natural teeth, and sometimes pay for Jaw disorders such as TMJ (temporomandibular joint dysfunction). However, medical plans rarely pay for other dental procedures. There can be rare instances where a DMD provides medical/dental services that can be covered under a medical plan, but these are tough cases.

The dental plan usually pays for services like you mentioned. You said, "She went in due to an infection in the jaw. The oral surgeon had to remove two teeth to remove the infection. She also had a root canal". My first thought is that removal of 2 teeth and a root canal are clearly dental expenses, and an oral surgeon is a proper provider for those services. If the oral surgeon was in-network, the billing rep in the oral surgeon's office is probably your best friend in trying to help you work out this claim. Call them. These billing reps know more about filing claims and working with the codes than any of us do!

 

[sturgbe]

Thank you all for the replys.

It is my understanding that after the oral surgeon removed the infection, he said that she will need a root canal on a seperate tooth due to the infection spreading. This was after the surgery and tooth removal.

She went in for the root canal on a seperate visit.

They paid the oral surgeon approx $1,800 on one visit and then paid the dentist $1,500 for the root canal. They told me their dental really stinks in that it really only pays for cleanings.

I find it hard to believe since the coverage is through a Big Fire Department in CA and they usually have decent coverage.

 

[ctg]

They paid the oral surgeon approx $1,800 on one visit and then paid the dentist $1,500 for the root canal. They told me their dental really stinks in that it really only pays for cleanings.

I find it hard to believe since the coverage is through a Big Fire Department in CA and they usually have decent coverage.

Does the plan have a maximum amount that the carrier will pay per year?

 

[somarco]

Dental has denied all coverage and so has BC.

but then you post this

They paid the oral surgeon approx $1,800 on one visit and then paid the dentist $1,500 for the root canal.

Who is they?

What do you know about the infection? Was it caused by a decaying tooth or gum disease? If so, this is a dental claim.

If there is another source for the infection it MAY be a medical claim.

Everyone says their dental plan is lousy.

 

[bill3173]

Everyone says their dental plan is lousy.

Yes, I had a Doc tell me that I sold him a shitty dental plan. I said what are you talking about, you've used the hell out of it. He then told me that he paid $500 in premium and they didn't pay more than $1200 that year, on the services he had completed.

I asked him how he got through med school if he couldn't figure out that $500 was better than $1700, he told me I was an asshole. However, some act like you've saved them a fortune when the dental pays anything.

 

[sturgbe]

They paid means that the insured/client paid out of their own pocket.

I know there are holes in this story but this is what is being translated to me. I manage all thir money and am a poor dental/health insurance guy...in fact, I don't do and leave it to the experts.

They (client) paid for the root canal becuase they said dental didnt cover it (remember, they said it was a crappy plan) but I am having a hard time believing dental wouldn't even pay 50% up to a max (say $1,000).

Also, if both insurance plans wouldn't cover it, isn't there a cash discount they should've received (do they have to ask for the negoiated rate)?

I believe the infection started from a TMJ surgery she had several years ago. I guess some screws or bolts went bad????

This is what I have:

1.Get EOB and SPD along with all bills.
2.Talk to the billing person at both offices: dental & surgeon
what questions should they ask these billing reps?
3. anything else you suggest?

 

[somarco]

if both insurance plans wouldn't cover it, isn't there a cash discount they should've received (do they have to ask for the negoiated rate)?

When claim is denied there is no repricing (discount).

The EOB's should tell most of the story.