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donaldj

Foreign Dental Claim Denied

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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.

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I have no doubt that the insurance company can demand documentation of any such claim directly from the dentist.  The insurer is also entitled to have the claim properly documented with the appropriate procedure codes.  The fact that the dentist is in Ukraine does not allow basing a claim on documentation from the patients husband.

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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.

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This is a legal discussion forum and is not designed or intended to provide precise legal advice.  If you want a precise legal opinion you should hire a lawyer to do the researchand write the opinion letter.  

 

The legal answer to your question is that your wife's right to reimbursement for dental treatment is defined by your wife's insurance policy.  Reviewing a dozen claim forms from other insurers is not going to answer your question.  If you believe your wife's insurer is acting arbitrarily, her recourse may involve complaining to the state insurance regulator and/or litigation.  I doubt you will find any appelate court decisions or statutes regarding the specific requirements for submitting a claim or for lumping together three crowns as if they are one bridge.

 

In any event, I am quite certain that no insurer is going to be required to pay a claim based on a description of the treatment rendered to a patient written by the patient's husband.

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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.  

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This is not governed by law. The carrier is permitted to dictate what information and format is required for claim reimbursement. Submissions by the patient or the patient's spouse are irrelevant. I've been the administrator for self-insured plans, including ones with a large international employee base. One of the challenges in seeking treatment in a country other than the one where the plan is administered is that international providers typically only conform to what the standard is for the country where they operate. Your best bet is to have your wife contact the provider directly and ask if he/she will provide what is needed to have the claim approved. Many will if provided the specifics and asked by the patient. Your plan administrator should have a procedure for appealing any denials.

 

Itemized bills are the norm in the US, but not so in other parts of the world. Yes, the ICD codes can be and typically are required.

 

While you can request a summary plan description at any time, it isn't going to necessarily cover the internal policies and procedures to accept a claim.

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>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.  

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I am sure that there argument would be, if ERISA applied to foreign claims, that until the claim is properly filed, the clock doesn't begin to run.

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What isn't governed by law is what information the plan may require to process a claim. That is determined by your plan itself. Are you seeking reimbursement or is the Dentist? There are time limits, but not much if any recourse if they are not followed. 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.

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I will also tell you that when it comes to ERISA violations, on a scale of "Thank you for telling us, we'll have an investigator there first thing in the morning" to "Yawn...so whadda you want us to do about it?", a payment in over 90 days rates somewhere around, "Yeah, okay, we'll have a look when we get around to it - I don't know when - maybe next month sometime".


It's nothing if not a low priority.

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>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.

 

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>>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?

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Since we are unfamiliar with Serbian law and business practices, we have no way of judging whether it is fraudulent or everyday accepted business practices.

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This is not fraud. Not even close. Yes, the insurance carrier can require the claims contain certain information before they will pay them. An itemized bill is not an onerous burden. Nor are records from the actual medical provider as to which teeth were worked on. I know of no IC anywhere in the world (of the 50+ other countries I have dealt with- including Russia) who would accept a chart made by the spouse of the patient. One of the challenges of receiving care outside of the country where insured, is coverage of claims. Every plan has exclusions. Every plan reimburses different services at different rates. For example, the plan might exclude experimental practices or only cover local anesthesia, not general. It might pay only 50% of the cost of bridges made from certain materials, but pay 70% of bridges made from others. It may not pay at all if the treatment was outside what is indicated by American medical standards. For example, the plan may cover 70% of the UCR (usual, customary, and reasonable) costs of a bridge, which might include only local anesthetic, outpatient, no x-rays, and exlcude the cost of  post-op medication. If the bill includes fees for general anesthesia, hospitalization, x-rays, and her pain meds, those fees would be excluded. Without an itemized bill, the IC has no idea what services are being covered. Trust me, it is absolutely possible to obtain documentation from a Ukrainian dentist which would allow a plan to cover benefits due. Now, whether your wife's dentist is willing to do that, none of us can say. She can't either until she asks.

 

As far as the time limit goes, the regulations indicate how long it should take to render a decision for a properly submitted claim, but there is no penalty specified if they miss the deadline. You must exhaust internal administrative remedies for the denied claim before you can sue. Even then, more often than not, these sorts of minor procedural missteps fall under the "substantial compliance" doctrine. Translation, the courts provide no remedy to you and no penalty to the carrier. At best, you would be entitled to the benefits the plan states you are entitled to (once that has even been established), and possibly attorney fees, but that is not a given. You are going to need an itemized bill for that as well.

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>>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.

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>>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.

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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.

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