Dental claim Question?
My company was bought out in May 2007. My insurance provider before we were bought out was Delta. Under the new care, we have Aetna, and basically thrown into a dental plan as a hew hire.(Technally weren't new hire's though). So, in early November, I had oral surgery done. My Dentist wants over $1100. I was under the impression that my insurance would cover it.
WOW. Was I wrong. Apparently I have to be with Aetna for a year, before having major work done. NOBODY Informed me of this. I have the documentation that I was given, and nowhere does it state must wait a year.
Can you give me any suggegtions/advice for when I submit my claim letter. I really don't feel like I should have to pay.
Thanks in advance ;)
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Interesting.
You can write an appeal letter. It never hurts. If you've gotten your EOB, and I'm assuming you have, you'll need to reference the claim number, date of service and all that. Include that along with a copy of your insurance handbook.
I'd word it something like this:
Dear Appeals Department;
I'd like to appeal the decision not to pay my claim for oral surgery on November 2nd, 2007. (See attached explaination of benefits.)
The reason stated for denial is "insured must be with Aetna for 1 year prior to major work being done." However, as you can see in the enclosed copy of my handbook, that rule is not listed and I was not made aware of it prior to the date of service.
Please reconsider this denial.
Sincerely;
Me
Patient ID 123456
They will have to respond to you. If you haven't already, contact Aetna to get the correct address for the appeal. Also, ask your dentist to do the same. Perhaps he could give you a narrative as to why the work was done and why it was important that you didn't wait until 5/08.
Good luck!
Going from Delta to Aetna might be the main problem. Check to make sure that your dental plan is not a ppo plan. Your surgeon may not be a preferred provider under your plan. It is your responsibility to know all the details about your plan and it is your employers responsibility to make sure you get them. Dental work has basically three types of benefits. Preventative, basic and major. Most plans consider oral surgery basic and is usually covered at a higher percentage. Major procedures are usually covered at 50 %, and preventative at 100 %. Basic is at 70 -80%. Hope this answeres your question.
If you were covered by Aetna at the time the service was provided, the issue is whether a procedure was a covered service.
I have heard of waiting periods for prosthetic (crowns, bridges, dentures) but ordinarily oral surgery doesn't have a waiting period. However, it is possible that the PARTICULAR service(s) performed are not covered services; if this is the case, you are out of luck.
Your oral surgeon should be willing to help you out here.
Steve Bornfeld, DDS
Unfortunately you are likely out of luck. Insurance companies do this, and many other things, so that they do not have to pay as much money for you to be insured. Every dollar you spend is one they save. I would recommend talking to your HR person/department. This is policy is standard with all insurance companies so you will likely be wasting your time.