Hi all.
Quick back story, my dentists office let us know they were cutting ties with Delta Dental in Oct. 2022. In Jan 2023, we got notice they reached an agreement, and were working with Delta for this year. My benefits were the same this year as last year, which is a work offered PPO, in network only.
March 9, 2023 I went to my dentist. I had my cleaning and a filling done same day. I was told my insurance (Delta WA, PPO in network only) was in network and covered this. I did sign their estimate, and paid $107 that day for my portion with insurance.
ETA: There was no prior authorization done this visit. He had time to get me in for the filling the same day as my cleaning, which is when we found the cavity.
I took my daughter for an appointment March 20, 2023 for an exam, and scheduled an appointment for two weeks later for a filling replacement for me. The office called the day before my new appointment to inform me they weren’t actually in network and insurance denied all previous appointments. This was leaving me with over $700 in out of pocket cost.
I canceled that appointment and contacted Delta. Delta informed me it was the office’s responsibility to tell me they weren’t in network I contacted the office again, and they told me that their contract they met with Delta covered “99% of Delta patients,” but that my specific PPO wasn’t bought into, so I was part of that 1%, and that doc would work with me but that I’d still owe a balance.
I received a phone call and a voicemail on April 4, 2023 from the dentists billing saying that even though they weren’t in network, I should’ve been covered under “something else” (there wasn’t any explanation on what that something else was), and that they were working on/investigating it with their Delta rep.
Since then, it’s been radio silence until I received a bill from the office on June 9, 2023. There were no itemizations other than a $5 billing fee and a $47 debit adjustment. I sent an email requesting itemizations, called on June 11, 2023 asking for the same things I did in the email, and just heard back today. They said doc took $200 off for the insurance issues, but that Delta still was refusing to cover, and I’m expected to pay $580 (they took off the $5 fee) over two payments if I need a payment plan.
Bottom line is, I don’t have that for surprise medical fees. Do I have any type of recourse with this, or should I just prepare to have this go to collections and fight with them?
I added the text version of what Delta has for my EOB below but I can’t upload the actual image of it.
—— ——
.
.
Claim Notes
1,2
1,2
TOTAL
Service Image-1st PA
Limit Oral Eval
Service Date
03/20/2023
03/20/2023
Amount Network Deductible Paid By Your Billed Discount Applied Dental Plan
$34.00 $0.00 $0.00 $0.00
$98.00 $0.00 $0.00 $0.00
$132.00 $0.00 $0.00 $0.00
Questions? Contact Customer Service at: 1-800-554-1907 Claim Notes:
1 No coverage or benefits are available when services are provided by a dentist who does not participate in the Delta Dental PPO Network.
2 This procedure is not a contract benefit. It is a contract exclusion. The cost is the patient's responsibility.
YOUR BENEFITS SUMMARY | Benefit Period: 01/01/2023 - 12/31/2023
DeductibleInNetwork FamilyDeductibleInNetwork MaximumInNetwork TMJMaximum
paid-to-date annual
$0.00 $50.00 $0.00 $150.00 $0.00 $2,000.00 $0.00 $1,000.00
OrthodontiaMaximum TMJMaximum
paid-to-date lifetime
$0.00 $2,000.00 $0.00 $5,000.00
Benefit Period Maximum Remaining: $2,000.00
YOUR RIGHT TO APPEAL
You have the right to appeal any decisions in this Explanation of Benefits (EOB) if you disagree with them. You may appeal the decisions verbally or in writing. We must receive your request for appeal within 180 days of the date your claim was processed. Your request must include the decision you wish to appeal and reason it needs review, Please also include the claim number, member's name, patient's name if different from the member (i.e. your child), and the name or the dentist the patient visited. This information is tor identification purposes only. You can find detailed claim information on the front side of this EOB. Please contact our Customer Service Team at the number on the front of this EOB to request any internal rules, guidelines, plan details, protocols, and other relevant materials used to process your claim. Well handle your benefit determination appeal in accordance with state regulations and the provisions outlined in your plan. You'll receive a letter with our decision regarding your appeal within 30 business days. If you disagree with our decision on this first level of appeal, our letter will include information on how you may request an additional review. If you still do not agree with the decision after you have completed all levels of our appeal process, there are other avenues available to you. These may include, but are not limited to, civil remedies and review by regulatory agencies. It you request a review or an adverse benefit determination , we will continue to provide coverage for the disputed benefit period pending outcome of the review if you are currently receiving services or supplies under the disputed benefit. If we prevail in the appeal, you may be responsible for the cost of coverage received during the review period. The decision at the external review level is binding unless other remedies are available under the State or federal law.
If you wish to request an appeal, please call customer service, write, email, or tax:
Claim Appeal Representative. Delta Dental of Washington PO, Box 75983
Seattle. WA 98175-0983
Fax: 509.685.6662
Email: memberappeals@deltadentalwa.com
QUESTIONS?
Have questions about your claim, benefits and to go paperless? Call customer service or visit MySmile® personal Benefits Center at DeltaDentaWA.com for assistance, If you would like to use Washington Relay Service, simply dial 711 (the statewide telephone relay number) or 800.833-6384 to reach a communications assistant.
FRAUD & ABUSE
If you believe EOB contains misleading or false information, please contact our Fraud and Abuse Hotline at 800.211.0359.
YOUR PRIVACY IS IMPORTANT TO US
Delta Dental of Washington is committed to protecting the privacy of your dental health information. To view and print a copy or our Notice or privacy practices (NPP), visit DeltaDentalWA.com You may also request a printed copy by calling our privacy hotline at 888.338.0172
EDIT 2:
Not sure if it matters, but my employer is in Ohio, I live in PA, and the office is in Ohio.
I’m sure this doesn’t matter, but I figured I’d add also that this is a common thing with this practice. My mom and my cousin had the same problem with this dentist. There’s also countless google reviews stating issues with insurance and billing and surprise bills.
My mom got a call from them that she had a lapse in insurance when she didn’t, then they billed the wrong Delta branch and tried hitting her for $137. My cousin had tricare at the time and the office said they were in network, then billed her months later and sent her a letter they were firing her as a patient due to nonpayment.
Quick back story, my dentists office let us know they were cutting ties with Delta Dental in Oct. 2022. In Jan 2023, we got notice they reached an agreement, and were working with Delta for this year. My benefits were the same this year as last year, which is a work offered PPO, in network only.
March 9, 2023 I went to my dentist. I had my cleaning and a filling done same day. I was told my insurance (Delta WA, PPO in network only) was in network and covered this. I did sign their estimate, and paid $107 that day for my portion with insurance.
ETA: There was no prior authorization done this visit. He had time to get me in for the filling the same day as my cleaning, which is when we found the cavity.
I took my daughter for an appointment March 20, 2023 for an exam, and scheduled an appointment for two weeks later for a filling replacement for me. The office called the day before my new appointment to inform me they weren’t actually in network and insurance denied all previous appointments. This was leaving me with over $700 in out of pocket cost.
I canceled that appointment and contacted Delta. Delta informed me it was the office’s responsibility to tell me they weren’t in network I contacted the office again, and they told me that their contract they met with Delta covered “99% of Delta patients,” but that my specific PPO wasn’t bought into, so I was part of that 1%, and that doc would work with me but that I’d still owe a balance.
I received a phone call and a voicemail on April 4, 2023 from the dentists billing saying that even though they weren’t in network, I should’ve been covered under “something else” (there wasn’t any explanation on what that something else was), and that they were working on/investigating it with their Delta rep.
Since then, it’s been radio silence until I received a bill from the office on June 9, 2023. There were no itemizations other than a $5 billing fee and a $47 debit adjustment. I sent an email requesting itemizations, called on June 11, 2023 asking for the same things I did in the email, and just heard back today. They said doc took $200 off for the insurance issues, but that Delta still was refusing to cover, and I’m expected to pay $580 (they took off the $5 fee) over two payments if I need a payment plan.
Bottom line is, I don’t have that for surprise medical fees. Do I have any type of recourse with this, or should I just prepare to have this go to collections and fight with them?
I added the text version of what Delta has for my EOB below but I can’t upload the actual image of it.
—— ——
.
.
Claim Notes
1,2
1,2
TOTAL
Service Image-1st PA
Limit Oral Eval
Service Date
03/20/2023
03/20/2023
Amount Network Deductible Paid By Your Billed Discount Applied Dental Plan
$34.00 $0.00 $0.00 $0.00
$98.00 $0.00 $0.00 $0.00
$132.00 $0.00 $0.00 $0.00
Questions? Contact Customer Service at: 1-800-554-1907 Claim Notes:
1 No coverage or benefits are available when services are provided by a dentist who does not participate in the Delta Dental PPO Network.
2 This procedure is not a contract benefit. It is a contract exclusion. The cost is the patient's responsibility.
YOUR BENEFITS SUMMARY | Benefit Period: 01/01/2023 - 12/31/2023
DeductibleInNetwork FamilyDeductibleInNetwork MaximumInNetwork TMJMaximum
paid-to-date annual
$0.00 $50.00 $0.00 $150.00 $0.00 $2,000.00 $0.00 $1,000.00
OrthodontiaMaximum TMJMaximum
paid-to-date lifetime
$0.00 $2,000.00 $0.00 $5,000.00
Benefit Period Maximum Remaining: $2,000.00
YOUR RIGHT TO APPEAL
You have the right to appeal any decisions in this Explanation of Benefits (EOB) if you disagree with them. You may appeal the decisions verbally or in writing. We must receive your request for appeal within 180 days of the date your claim was processed. Your request must include the decision you wish to appeal and reason it needs review, Please also include the claim number, member's name, patient's name if different from the member (i.e. your child), and the name or the dentist the patient visited. This information is tor identification purposes only. You can find detailed claim information on the front side of this EOB. Please contact our Customer Service Team at the number on the front of this EOB to request any internal rules, guidelines, plan details, protocols, and other relevant materials used to process your claim. Well handle your benefit determination appeal in accordance with state regulations and the provisions outlined in your plan. You'll receive a letter with our decision regarding your appeal within 30 business days. If you disagree with our decision on this first level of appeal, our letter will include information on how you may request an additional review. If you still do not agree with the decision after you have completed all levels of our appeal process, there are other avenues available to you. These may include, but are not limited to, civil remedies and review by regulatory agencies. It you request a review or an adverse benefit determination , we will continue to provide coverage for the disputed benefit period pending outcome of the review if you are currently receiving services or supplies under the disputed benefit. If we prevail in the appeal, you may be responsible for the cost of coverage received during the review period. The decision at the external review level is binding unless other remedies are available under the State or federal law.
If you wish to request an appeal, please call customer service, write, email, or tax:
Claim Appeal Representative. Delta Dental of Washington PO, Box 75983
Seattle. WA 98175-0983
Fax: 509.685.6662
Email: memberappeals@deltadentalwa.com
QUESTIONS?
Have questions about your claim, benefits and to go paperless? Call customer service or visit MySmile® personal Benefits Center at DeltaDentaWA.com for assistance, If you would like to use Washington Relay Service, simply dial 711 (the statewide telephone relay number) or 800.833-6384 to reach a communications assistant.
FRAUD & ABUSE
If you believe EOB contains misleading or false information, please contact our Fraud and Abuse Hotline at 800.211.0359.
YOUR PRIVACY IS IMPORTANT TO US
Delta Dental of Washington is committed to protecting the privacy of your dental health information. To view and print a copy or our Notice or privacy practices (NPP), visit DeltaDentalWA.com You may also request a printed copy by calling our privacy hotline at 888.338.0172
EDIT 2:
Not sure if it matters, but my employer is in Ohio, I live in PA, and the office is in Ohio.
I’m sure this doesn’t matter, but I figured I’d add also that this is a common thing with this practice. My mom and my cousin had the same problem with this dentist. There’s also countless google reviews stating issues with insurance and billing and surprise bills.
My mom got a call from them that she had a lapse in insurance when she didn’t, then they billed the wrong Delta branch and tried hitting her for $137. My cousin had tricare at the time and the office said they were in network, then billed her months later and sent her a letter they were firing her as a patient due to nonpayment.