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So my mom took my 11 year old brother to the dentist to get a crown done in March 2014.she paid the patient portion and everything else was supposed to be covered by the dental insurance. Since then all other dental visits were always paid by the insurance and patient portion was always paid. Everything was in good standing. But now, 2 years later, we receive a statement from the dental office saying that the insurance did not cover the crown that was done 2 years ago and that we owe 1,000 plus dollars for the crown from March 2014. Are we responsible for that? And if so, is there any way to appeal this?

  • Can you get an explanation of benefits from the dental insurer? I'd start there, either a decline or the explanation of benefits if it was covered. – quid Mar 28 '16 at 23:07
  • Based on my recent experience, reasons that the crown or ancillary work might not have been covered--crown type (my ins would pay for all metal or front porcelain/back metal but not all porcelain) and anesthesia (not covered). – mkennedy Mar 29 '16 at 19:43
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Short answer - yes, you're responsible. Your mom, that is.

Longer answer: When you go to a doctor's office, you sign a statement that the insurance payments on the bill are estimates, and the actual amounts will be adjusted when the insurance pays. Whatever insurance doesn't pay - is on you.

You need to check with the insurance whether they in fact declined to pay, and if so - why. If they didn't decline, they should send you a statement saying how much they paid and how much you still owe, and if they did decline - they should send you an explanation for the reason. That explanation should also include the ways to appeal, although it is likely to be too late for that.

  • Its not quite as simple. Often when an office accepts an insurance they agree to bill things at a certain rate. So while the office might normally bill 200, they agreed to charge covered patients 100. Then insurance will cover some of that, say 75. The patient then owes 25. Some offices try to break their agreement though and balance bill the 100 discount and ask the patient for 125. If that's the case the insurance company should be notified to put the smack down on the office. I'm not sure if dental works in this way too, but its possible. – Andy Mar 28 '16 at 23:58
  • Dental does, generally, also work that way. There's a lot of moving parts, it's best to start with documentation, either a decline or an explanation of benefits, from the carrier. – quid Mar 29 '16 at 0:09
  • @Andy that is why I suggested checking how much they still owe based on the insurance statement, not the doctor's. – littleadv Mar 29 '16 at 0:27
  • Many people don't understand EOBs and might believe the dr explanation, and you'll need to know exactly how it all works to stop the office from trying to put things to collections. I know, i had this fight with my dr and even getting them to understand is difficult. – Andy Mar 29 '16 at 0:31

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