Dental Claim for Crown not immediately approved

[slackmax]

I just received a scary EOB for a scheduled crown. I haven't even had the crown put on yet, but the dentist apparently has already submitted the claim, for tooth buildup ($385) , and the crown itself ($1,050). It says I owe 100% of the charges at this point, not even a reduced amount.


But... a remark on the EOB is requesting the dentist to 'please resubmit with a narrative of medical necessity'.  So it's not a denial, but a request for documentation.

Some background. The tooth getting the crown had partially cracked off. The dentist wanted to do a crown, but I asked about a filling instead, and he agreed to try it, but said it might last for years, or might not.. The filling came out after a month, and I went back and requested a crown.

The insurance co paid the claim for the filling, no problem. 

I called the dentist's office about the request for 'narrative of medical necessity' and the clerk said this particular ins co does that sometimes, and not to worry about it, and that she would have to write a letter to them. She said she had not received the EOB yet, saying the mail service is often late there. (Same zip code I'm in though, so why is her mail late?)

 Maybe the insurance company thinks I ought to just get another filling? Too late for that. Already had the tooth buildup for the crown.

I called the insurance co and asked about the crown claim, and they said they will 'make a decision' when they get the 'narrative of medical nesessity' and also want an xray taken within the last 6 months. I couldn't get a reason out of the guy for the xray, but I assume it's to show the cracked off tooth needing the crown. But an xray 3 months ago would show the tooth before it cracked, so I just don't understand that 6 month window. There's no mention of an xray in the EOB. Fortunately, the dentist did an xray when he put in the filling, and another xray when doing the crown buildup. If they want an xray showing a noncracked tooth, I have to go back to a year ago or more.

He didn't say anything about the filling, and I didn't mention it. We only talked about the EOB for the crown.

I'm wondering if the insurance co has a problem with the fact that I tried the filling first, and that now they have to pay for a filling and a crown on the same tooth.

I thought about postponing the installation of the new crown, but now I think I will go ahead and have it installed on the sheduled date, with or without the claim being approved yet, since I need it anyway.   

Are dental insurance companies into denying claims for crowns these days? Is the filling in the same tooth a problem?
Or is the dental clerk right, that I don't have to worry?

Thanks for reading this long post.  Any input appreciated! 

[Metalcat]

It means that they probably provided an x-ray that doesn't show enough damage to justify the crown. This is common because the way teeth crack is always on an axis that doesn't show up in a 2D x-ray.

Where I am, whenever a crown is submitted, a dentist at the insurance company has to look at the images and decide if they agree that a crown is necessary. That's why pre-approvals are sent.

If they say no, it means they haven't seen enough evidence yet to justify the crown. As I said, a tooth can be split right in half and an x-ray may not show it. That's where extra photos are important.

The admin may know what they're talking about and know that they have additional photos to send that will clearly justify the crown, or they may be a clueless and inexperienced staff member with no real knowledge of the insurance industry.

I would prepare yourself to possibly have to pay for it unless and until you see that it's been approved, but if it's already been cut for the crown, you can't back out at this point.

ETA: they don't care about you trying the filling first, and they don't really care about the history of the tooth. Insurance companies deny anything they can, so if they haven't seen enough evidence to justify a crown, they will deny.

It's up to the dentist to document sufficiently to provide this evidence. That's why photos are so popular now.

[slackmax]

Thanks for the reply, Malcat. I remember the dentist saying 'Lets take a picture' but I thought he was referring to an xray. Don't know. Maybe they have actual cameras in the equipment they have around you at the dentist these days. 

The front half of the tooth broke off, and I still have it in a small glass jar, lol.

I'm going to let the dental office handle it. I'm sort of at their mercy, though, since if they 'fail' to get the claim approved, they win, insurance co wins, and I lose. The dentist can charge me full price, instead of the 'approved amount'. And the ins co doesn't have to pay anything. 

If I were a little bit more cynical, I'd think the dentist doesn't want the claim to be approved. Can I be that cynical? Surely not. 

Well, I can also file an appeal on my own, which is spelled out in the EOB letter.

But here's hoping the dental clerk is right, and I can just let her resubmit the claim with more information,  and not worry about it.     

If it ends up being denied, maybe I can get him to charge me less than the full price. One can hope. Gotta keep the customers happy, right? lol.       

[Metalcat]

Thanks for the reply, Malcat. I remember the dentist saying 'Lets take a picture' but I thought he was referring to an xray. Don't know. Maybe they have actual cameras in the equipment they have around you at the dentist these days. 

The front half of the tooth broke off, and I still have it in a small glass jar, lol.

I'm going to let the dental office handle it. I'm sort of at their mercy, though, since if they 'fail' to get the claim approved, they win, insurance co wins, and I lose. The dentist can charge me full price, instead of the 'approved amount'. And the ins co doesn't have to pay anything. 

If I were a little bit more cynical, I'd think the dentist doesn't want the claim to be approved. Can I be that cynical? Surely not. 

Well, I can also file an appeal on my own, which is spelled out in the EOB letter.

But here's hoping the dental clerk is right, and I can just let her resubmit the claim with more information,  and not worry about it.     

If it ends up being denied, maybe I can get him to charge me less than the full price. One can hope. Gotta keep the customers happy, right? lol.     

The dentist likely does not want the hassle of the claim not being approved, because that's exactly the type of thing that patients lose their shit over.

The cameras used these days are a separate piece of equipment from the x-rays, but yes, a lot of dentists call x-rays "pictures", so it's hard to say. You would probably know if they took a photo specifically because they tend to show you when they do.

Overall though, don't stress about it until you have a reason to stress about it. It is normal for insurance companies to ask for additional documentation.

Also, maybe try to find out why your tooth broke. It's common, but it's not normal, and can be prevented.

[Dicey]

You sound cynical enough as it is. Even your comment about the mail/zip code sounds off the wall to me. Would having to pay for a crown OOP financially destroy you? Preserving your dental health has significant value.  Why are you stressing so much about this?

[Sibley]

I've worked for a health insurance company, and currently for auto insurance. You are stressing over something that is actually pretty routine. They're asking for more information. The dentist office will provide the additional information. That information will be reviewed, and then a coverage determination will be made. Given that half your tooth is missing, as long as the dentist office is even halfway competent, it'll be approved.

Figure out how to chill.

[slackmax]

I've worked for a health insurance company, and currently for auto insurance. You are stressing over something that is actually pretty routine. They're asking for more information. The dentist office will provide the additional information. That information will be reviewed, and then a coverage determination will be made. Given that half your tooth is missing, as long as the dentist office is even halfway competent, it'll be approved.

Figure out how to chill.

LOL.   Well, I'm doing my best to chill, bro. I called up the dentist office again. They still haven't received the explanation of benefits, so I told them I'd give them a copy of mine.

I asked the clerk a lot of questions, and got reasonable answers. I'm now going to allow myself to turn it over to her, and just 'chill'.  I can't chill until I know I've done all I can think of to resolve the problem at hand.

[Metalcat]

I've worked for a health insurance company, and currently for auto insurance. You are stressing over something that is actually pretty routine. They're asking for more information. The dentist office will provide the additional information. That information will be reviewed, and then a coverage determination will be made. Given that half your tooth is missing, as long as the dentist office is even halfway competent, it'll be approved.

Figure out how to chill.

LOL.   Well, I'm doing my best to chill, bro. I called up the dentist office again. They still haven't received the explanation of benefits, so I told them I'd give them a copy of mine.

I asked the clerk a lot of questions, and got reasonable answers. I'm now going to allow myself to turn it over to her, and just 'chill'.  I can't chill until I know I've done all I can think of the resolve the problem at hand.

Is this an onerous amount of money for you?

I know that when I got hit in the face and crowned my front tooth a few decades ago, not knowing whether insurance could cover it was terrifying.

[slackmax]

Malcat wrote:

  <<  Is this an onerous amount of money for you?

I know that when I got hit in the face and crowned my front tooth a few decades ago, not knowing whether insurance could cover it was terrifying.  >>

Ah, you can relate!  Thank you.

Fortunately I wasn't in a fight, or hit with softball or anything,  that caused the tooth to break. I just contacted it with a lower tooth while chewing, and it came off. Must have been partially cracked off internally already. Maybe I'm grinding my teeth at night.   

It won't be onerous if I have to pay full price, but just very disappointing, since I have been successfully using the same insurance at this dentist  already for a few years.

I was expecting to get a big discount, and now have the prospect of paying full price. No fun. The only bills I pay that are bigger than this potential bill are my annual property tax bills.

[Metalcat]

Malcat wrote:

  <<  Is this an onerous amount of money for you?

I know that when I got hit in the face and crowned my front tooth a few decades ago, not knowing whether insurance could cover it was terrifying.  >>

Ah, you can relate!  Thank you.

Fortunately I wasn't in a fight, or hit with softball or anything,  that caused the tooth to break. I just contacted it with a lower tooth while chewing, and it came off. Must have been partially cracked off internally already. Maybe I'm grinding my teeth at night.   

It won't be onerous if I have to pay full price, but just very disappointing, since I have been successfully using the same insurance at this dentist  already for a few years.

I was expecting to get a big discount, and now have the prospect of paying full price. No fun. The only bills I pay that are bigger than this potential bill are my annual property tax bills.

So disappointing, but not actually stressful.

Yes, I understand, I just broke the veneer on the tooth next to that crown from 20 years ago, and th crown needs to be replaced as well, and the root canal that was originally done was done improperly (along with the original crown and the matching veneer), so I need gum surgery, a new crown, and a new veneer. If I'm charged full price, it will be nearly $10,000 total, but the dentists are my friends, so I might get a discount.

I broke it during a trip for other medical treatment that cost me another $10,000 out of pocket because I had to get it in another country.

Health costs happen. Congrats on going this long without too many of them, and hopefully that winning streak keeps going, and you don't get a $20,000 health cost month like mine at any point.

[slackmax]

Malcat,

Thanks for your useful and supportive input in this thread, and may tour health care costs be light going forward!