Can a health insurance company deny a claim when they initially said they would pay it??

Question

I went to the dentist because I dislocated my jaw. The dentist had to fit me for a splint to set it but only after the office's billing person came in and explained that she had spoken with my insurance and was told that they would pay 80% and I'd be responsible for 20% of the splint. I had to sign a paper acknowledging my 20% due and then they would do the splint. I got my splint, paid my 20%, and got to healing. I got a bill today from the dentist saying I'm responsible for the remaining 80% because my insurance denied the claim. I know that speaking to someone at the insurance company "does not guarantee payment", as I hear every time I call, but who should I take this up with? The insurance compant who first said they would pay it but are now refusing or the doctor who talked with them initially but now wants more money? The remaining 80% is over $500 and I simply can't afford it.

Answer 1

first u try to talk with the company and if they will refuse then straight away go to State Commision Insurance, they can help u.

Answer 2

You need to call your insurance company and find out exactly why the claim wasn't paid.  What did your explanation of benefits (EOB) from the insurer say?  If they truly rejected the claim, then they would have notified you directly.  (I find it odd that you got a bill from the dentist before you received the Explanation of Benefits from your insurer...perhaps they didn't even receive the claim.)

It could very well be a coding issue - medical claims are billed using CPT codes, and not all dentists offices use CPT codes to bill.  If that's the case, then it should be a fixable problem.  Someone just has to manually work with the claims to get them through the system.

Or, if there is another specific reason why it isn't being paid, that can help you determine what to do from there also.

Answer 3

You contact the State Insurance Commission.  

  

My wife had a mammogram which was 'suspicious', and the Doctor requested an MRI.  Blue Cross Blue Shield verbally approved the MRI, and later rejected the claim.

  

We protested to the State Insurance Commission, and BCBS changed their mind (before the ruling came back).  They paid.

Answer 4

Call a friend who might be a lawyer or call your own lawyer.

Option 1: Argue, argue, and argue for that 80percent. Many insurance companies are theives living off people's trusts. Argue for your money, make a claim and argue argue and argue. Also you can threaten them with lawsuits or changing companies

(((((((((((((((((((NOT the first choice to take)))))))))))))))))))

Option 2: Research. Go to your insurance website, and read their policy. Study the insurance policy and see why they might not be paying the 80%

Option 3: Call lawyer, and discuss it over the phone.

p-------------------------------------...

Option 2: Hardest to do, and takes time

Option 3: Easiest to do but costs money.

The problem is that insurance companies are very corrupt. I would file a lawsuit. they usually expect you to go in circles and give up. 500 dollars isnt a big amount of money but filing a lawsuit with a lawyer who understands your problem and will work with you for your benefit is the best way to stick it to these b******s.  

Answer 5

Call the insurance company and find out why it was denied. Often these things get denied b/c the dr coded the bill one way -- had they used a different code it would have been covered.  

It could be something as simple as they thought it was a cosmetic procedure and not because of an injury.

So before you go getting all worked up--- call your health insurance company and speak to them.

Answer 6

Under your circumstance,I suggest here for you to have a visit.http://health-insurance.expert-tip.info/...

Answer 7

Well, before anyone can help... we need to know why they denied it. Are they saying its a not covered? & If so, why? Is it dental insurance? or medical? You need more info from the insurance company... They can help. If you don't get help from them, try speaking with HR (if your insurance is through a job) or your broker if its private/individual insurance.  

Answer 8

Why did they deny the claim? If you disagree with the reason, appeal it. You should have also gotten a copy of the denial. On it is the appeal process or check your policy for the process. Get the dentist to write a letter explaining his position.

Answer 9

Yes, they can.  

But that's not the issue here.  

You call your insurance company, and tell them you need to appeal this claim.  See, some non-thinking person saw the paper, saw it was from a dentist, saw that you have no dental coverage, and rubber stamped it declined, without ascertaining if it was really a dental claim or a medical claim.  It's up to YOU, to make your insurance company take a closer look at it, to pay this.  

This is very, very common and happens all the time.  Hey, it's happened to ME, that a dentist claim was denied by my  health insurer (it took two appeals, but was eventually covered).   You just have to appeal the denial.