Complaints

• Initial Complaint

  04/20/2022

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  Dr Holly L****** received the Pre-Treatment Estimate for a bridge from Delta Dental on 02-10-21. Based on the estimate of $1,641, I agreed to the bridgework and had the procedure done 04-07-21. After I had the procedure, Delta Dental denied the claim. Based on the new amount, I would owe $2,767 for the procedure, over $1,000 more than what I was told would be my responsibility. (Adjusted by Dr L******’s office to $848.54) Delta Dental told me my claim was re-reviewed after I had the procedure done and the reviewer chose to deny it. Delta Dental stated, “Based on your health plan, this service was denied due to major restorative services previously being done on tooth 29, 30 and 31 on 06/20/2016. Per your plan major restorative service are allowed once every 5 years. The 5 year mark had not been met and you are therefore responsible for the full billed amount.” Delta Dental initially approved the procedure, and then denied it after I had the procedure. Apparently they did not review everything beforehand sufficiently. If they had noted that the five-year claim limit would have been okay after 06-20-21, I would have been satisfied with waiting the extra three months to have the procedure done. Instead, Delta Dental dropped the ball on their end, and then denied the procedure after the fact. As Delta Dental gave my dentist and I the Pre-Treatment Estimate, and had plenty of opportunity to review my files before I had the procedure, I feel that they should be responsible for the additional charges. Dr L****** and I acted on good faith in scheduling this procedure, it was Delta Dental’s error in not catching the time issue on their side. Especially since this error was entirely due to Delta Dental’s inattention to the initial estimate. If the 5-year limit had another three months to go for this procedure, they should have caught this problem before they approved the procedure, not waited until it was already done and then deny the claim after the fact. See attachments

  Business response

  05/03/2022

  Good Afternoon, 
  
  Attached is the response to Ms. **********'s complaint. Thank you.  
  
  Elena 
  
  
  May 3, 2022
   
  BBB of New Mexico
  **** ********* ** ** *** *
  Albuquerque, NM 87109
   
  Re: Complaint ID-********
   
  To Whom It May Concern:
   
  On April 20, 2022, Delta Dental of New Mexico (DDNM) received your inquiry on behalf of a DDNM Consumer regarding the processing of their claim.
   
  The claim has been reviewed and will be reprocessed based on the Pre-treatment Estimate that was approved for the consumer. DDNM apologizes for any frustration caused to the consumer regarding the processing of their claim.
   
  Please let me know if I can further clarify any details related to Complaint ID ********.
   
  Best regards,
   
  Elena H******
  Quality Analyst
  Delta Dental of New Mexico
  

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