I blogged a while ago about worries that I had with dental costs here. I've now completed "My Treatment Plan" which included 2 crowns and 3 fillings. Yuck!
I had already paid $800 for my treatment and my plan covers 80% of the stuff I was getting done, so according to some calculations I did it looked like I might actually get a little money back. Last week, I received a $1,300 bill from my dentist. Yeah, I was surprised too.
I started by calling my dentist who let me know that the claim for one of my crowns had been denied. Denied? Um, how can your insurance deny something that they say that they cover?
I learned a bit more about the insurance process today while I was on the phone and I can now answer that question. So if you go or will ever go to the dentist, this might be some helpful information. I know it all seems very basic, but I really did think that my insurance would cover the procedures that it listed on my policy. Silly me!
Each time a dentist submits a claim they need to attach x-rays and such showing why they needed to do 'X' treatment. The insurance company then has their consultants look over this information and decide whether or not the procedure was indeed "necessary" before they will cover it. If the consultant deems it UNnecessary, then the patient (me in this case) will need to pay the full cost of the treatment.
This all sounds VERY reasonable and I understand why they need to go through this process because dental insurance companies don't want to pad the pockets of dentists that are doing unnecessary procedures. When I talked to my insurance company on the phone, they told me that it was good practice to have any procedure over $250 pre-approved with them before actually getting it done. Once again, excellent information, but 4 months too late.
Now what do I do? Well, the insurance company told me that I need to have my dentist office file an appeal explaining why my treatment was indeed necessary. You can file up to two appeals. If the appeal is granted then the insurance will cover it. If not... well I guess I will have a big unexpected bill coming up.
So hopefully this will be a positive learning experience and my claim will be covered. What can you learn from this and why am I sharing? Make sure that you get any procedure pre-approved EVEN if your policy says that it is covered.
Lesson learned.
Hey, even if the appeal process doesn't work out, check to see if you can go through the state to appeal. I know it sounds crazy and extreme, but my mom had to do that for "unnecessary" surgery my sister actually needed. The two appeals got shot down, but when she went through the state, eventually the insurance company covered the $13,000 surgery. Good luck!!
ReplyDeleteThanks, I'm hoping that I don't need to go that far, but it's always good to know what my options are. The dentist office told me that the insurance company hasn't actually sent the official denial paperwork (even though it has been denied for sure), so they have to wait on that before they can even file an appeal.
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