donaldj

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  1. I am not stupid. The illegal part is not asking for itemized bills. The illegal part is taking 182 days to ask for that info. They have never sent written notice requesting to go past 90 days. It would cost me $100 to pay someone in Ukraine to go out and get that information and ship it to me. Yes, I can and will get the info but only after exhausting other avenues. US DOL called today and will be contacting Chico's HR manager shortly. Your comments are so biased that they are of little real value.
  2. Ms.E: It is a self funded plan. I see no "need to comply" with illegal requests that are a violation of federal regulations. Evidently you do. The employer and insurer both notified me to call if any questions. I called each 3 times and left voicemail. They evidently chose to ignore me. I understand you see no problem with that. I do.
  3. Neither the insurance company or the retail company HR manager would return my calls for last 7 days. Complaint has been escalated to US DOL.
  4. >>Your best bet is to appeal the denial through the plan's established procedures (should be outlined in the letter) and supply what is being required. They have 90 days to process the claim, and if rejected, explain why. Searching for more than 90 days for items to nitpick about is a violation of federal law.
  5. >>Your best bet is to appeal the denial through the plan's established procedures (should be outlined in the letter) and supply what is being required. We have already done that. They just made up another thing they wanted. If we supply the new thing they want, they will probably just make up something else. I will be calling the HR rep to complain about this and try to make sure this is the FINAL thing they need. We have been through this loop several times already. >> Without an itemized bill, the IC has no idea what services are being covered. My stepdaughter went to St Petersburg Russia, and laid 450k rubles down on the medical center front desk for a 3 day surgical operation. There were very few things itemized on the bill (about 4 total), mostly one item for 340k rubles, and 2 for anesthesia. United Healthcare paid it right away.
  6. >>Your best bet is to appeal the denial and supply what is being required. According to Ms Elle, this is the proper process: Sergei, a foreign exchange student from Siberia, goes to Arkansas dentist and gets 3 crowns. Gets receipt with US procedure codes and US tooth numbers. However Sergei's Siberian Insurance Co requires Russian tooth numbers and Kossack V5.1 claim codes. According to Ms Elle, Sergei simply needs to go back to the little old lady behind the Arkansas counter and ask for another receipt with Russian tooth numbers and Kossack V5.1 claim codes. Sure, no problem. Zero chance of that happening. It would be fraudulent business practices for Siberian Insurance Co to say they accept claims from US dentists if it was impossible to get the necessary documents. So Siberian Insurance Co evades the fraud allegations by going ahead and paying 100 claims for items $100 or less. They also reject 100 claims for items over $100, due to "insufficent documentation". Now Siberian Insurance Co can advertise that they accept US dentists and have paid many, many claims from US dentists. So according to MsElle, this is normal business procedures? Or is it a scam?
  7. >Yawn. It's nothing if not a low priority. That behavior has been obvious for months. Not sure if the host company corporate ethics officer will yawn about the complaints they have received for this situation.
  8. >This is not governed by law. You do not consider Erisa regulations to be federal law? They have violated Erisa regulations by taking more than 90 days to process a claim.
  9. The state insurance regulator does not apply to self-insured companies(I have already complained there). The claim included a complete narrative from the dentist on all the processes that were done. i included a one page translation from international tooth numbers to US tooth numbers, and commented by each tooth what work was done. I did this because a claim 3 years ago to same carrier was denied because I had international tooth numbers on it instead of US tooth numbers (they just couldn't figure out how to translate the numbers....). In 30 years of working, I have never received a copy of a policy/contract for company supplied dental/medical insurance. All that is supplied is a booklet containing vague/general terms, like 50% payment for a crown, etc. I am seeking "legal advice" because the issue is still under negotation using an agency called Health Advocates.
  10. Thanks for info. But this is a legal forum and I am looking for precise legal responses rather than opinions. Such as what wording is needed in the policy and claim form in order to "require" procedure codes. For your info, I have looked at about a dozen foreign claim forms today. One major carrier requests a claim code in space 29, and then says if claim code not available enter a description in space 30. So requirements might vary, and code is not always "required". Also I am mainly interested in whether 3 bridges can be combined into one dentist supplied price vs 3 bridges with a supplied price for each one, rather than whether a claim code is needed.
  11. My wife went to Ukraine to have various work done including 3 bridges. The Ukraine dentist receipt included a $1400 item for the 3 bridges. Delta Dental denied the claim saying we needed a separate claim item from the dentist for each bridge, also identifying teeth involved on each bridge. I had included a chart showing teeth involved with each bridge, but it was my chart and not the dentists. Is this a legal basis for denying the claim? Also they have procrastinated greatly in processing this claim (6 months). According to ERISA regulations, I thought 90 days was the max they could delay a claim without written notification? Also are the US procedure codes required to be given by a foreign dentist?thanks for any info.