Drama over Dental Insurance Claim for Crown

[John Galt III]

I'll give a synopsis here first. I'm having a new crown put on. Insurance co sent me an EOB saying the are approving nothing yet, and are requesting 'please resubmit with narrative of medical necessity'. Dental clerk says not to worry, she will handle it. Complication is that the same tooth had a filling that only lasted a month, then I opted for the crown. Don't know if that is a problem for the claim.

Whole post follows : 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 necessity' 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 scheduled 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!

[Aerides]

(I know some browsers have an issue with placement of paragraphs, so I went ahead and edited to break up the wall-o-text a bit. Hope that's ok)

[Aerides]

Your specific insurance matters. Mine didn't cover but 50% of anything totally non-necessary, and even then had an annual cap around $1500. Basically, crowns, it would pay 50%, pulling a tooth or a filling would be 100% - crowns being somewhat cosmetic, etc.

So the terms of your insurance are a thing to consider.

That said, go ahead with the crown, of course at this point, and you can at least reimburse yourself if you have an HSA? As far as the mail issues, yes, first class and even priority is still all over the place, even in the same towns, so that's real. And yes I would let your dentist and insurance work it out - especially since the clerk seems somewhat familiar with this provider - and then put it out of your mind until they both say it's final.

[Amethyst]

Have you spoken to your insurance co. rep yet? They should be able to tell you what they've received, what they pay, and why, for claims on a certain date and for a certain tooth (teeth are numbered 1 -32).

I have to call Humana fairly often about dental issues. Partly this is because the dental insurance is secondary to our primary insurer, and Humana won't pay until they get a copy of the primary's EOB.

Example: Husband needs a crown on #28 and an implant/crown on #31. Dental office wants to charge us the insured rate for #31, but full rate for #28 because "it had a crown on it before." Our Humana rep said they had no record of ever having paid out on #28. She said they would reimburse the crown to the usual scheduled amount.

Quote:

Originally Posted by John Galt III I'll give a synopsis here first. I'm having a new crown put on. Insurance co sent me an EOB saying the are approving nothing yet, and are requesting 'please resubmit with narrative of medical necessity'. Dental clerk says not to worry, she will handle it. Complication is that the same tooth had a filling that only lasted a month, then I opted for the crown. Don't know if that is a problem for the claim. Whole post follows : 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 necessity' 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 scheduled 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!

[John Galt III]

Quote:

Originally Posted by Aerides (I know some browsers have an issue with placement of paragraphs, so I went ahead and edited to break up the wall-o-text a bit. Hope that's ok)

Thanks. Yes, in this website, I am stuck with wall-o-text formatting, lol.

[John Galt III]

Quote:

Originally Posted by Amethyst Have you spoken to your insurance co. rep yet? They should be able to tell you what they've received, what they pay, and why, for claims on a certain date and for a certain tooth (teeth are numbered 1 -32). I have to call Humana fairly often about dental issues. Partly this is because the dental insurance is secondary to our primary insurer, and Humana won't pay until they get a copy of the primary's EOB. Example: Husband needs a crown on #28 and an implant/crown on #31. Dental office wants to charge us the insured rate for #31, but full rate for #28 because "it had a crown on it before." Our Humana rep said they had no record of ever having paid out on #28. She said they would reimburse the crown to the usual scheduled amount.

Yes. I called the ins co and spoke about only the crown claim, nothing about the filling in the same tooth. The ins claims guy was just reading his script, no reassuring statements. He said they would 'make a decision' once the claim was resubmitted. I wonder about your dentist wanting to charge full rate on one of the teeth. Is that because he thinks that tooth would be denied coverage? I guess it's not a secret that dentists would make a lot more money if every claim were denied, since they could bill at the full rate (as long as their customers didn't leave them, lol).

[Amethyst]

The office ladies got the information from some insurance pricing site they use. Yes, they stated that they did not expect to get reimbursed on that tooth because there was a crown there already. I knew our insurance would only pay if that crown was at least five years old, but had no idea how old it was, so that's why I went right to the insurance rep. Next I'll see what the dentist office billing people have to say.

Quote:

Originally Posted by John Galt III I wonder about your dentist wanting to charge full rate on one of the teeth. Is that because he thinks that tooth would be denied coverage? .

[Teacher Terry]

I always get my dental work preapproved so I know if they are paying and how much.

[stepford]

Could be worse. I had to have a crown re-done back in October. $1800 surprise (had been $1100 for the last one). No insurance, no choice...

[Montecfo]

I would attempt to negotiate a lower rate for the crown if it is denied by your insurance.

I had a crown break. I went to see the dentist to get it replaced. They said after checking into it then my insurance wouldn't pay for it because the crown was not at least 8 years old. So I could wait till December, or I could do it now for I think he said $800, versus the 1400 with insurance.

I opted to just wait, as the broken crown was not affecting anything. And that's where I am today it's been probably 2 years ago.

[Bamaman]

I don't know if it's my imagination, but are prices on dental services going up exponentially?

My regular dentist charges $800 for crowns, and it takes 2 visits and 2 weeks to get them.

My secondary dentist charges just over $700 for crowns, and she scans the mouth and has a CNC machine that carves the crown out of porcelain in 6 minutes. 1 hour and I'm out the door in total.

What gets me is a root canal. Our husband-wife root canal specialists charge $1,000 a root canal, up from $800. They accept cash and ATM cards only. Insurance is not accepted and they won't file papers even. I drove 40 miles to a dental surgeon and got a root canal on my BCBS insurance for far, far less.

I'd just hate to think what an implant would cost. Last time our M.D. surgeons wanted almost $2250 plus $850 plus $850 to remove the tooth plus a crown would be required. Almost $5K. Ouch.

[aja8888]

Quote:

Originally Posted by Teacher Terry I always get my dental work preapproved so I know if they are paying and how much.

Me too, especially now that Medicare "takes" care of it by telling you nothing is covered! LOL!

[CSdot]

I am finding that our health insurer BCBS is going out of its way to make processing claims difficult. For example, declining coverage for prescription refills unless the Dr sends them proof of medical necessity each year. WTH? Just puts the insured in a bad position because we have had to pay full freight for a refill (for a child leaving town for school the next day) when we couldn't wait for the Dr. to get the authorization sent. Seems the actual prescription should be proof that the Dr believes the medicine is still necessary.

As for dental, my father in law who is a dentist said dental insurance probably costs the patient more per year than they get back. For this reason, I self insure for dental. Even when I had dental, I was responsible for 50% of the crown cost. I had a nagging feeling that on a $1,200 bill, I was paying $600, while the insurance company probably got their $600 half knocked down to maybe $200, or about what I paid per month at the time for dental insurance.

[Buckeye]

Quote:

Originally Posted by Bamaman I don't know if it's my imagination, but are prices on dental services going up exponentially? My regular dentist charges $800 for crowns, and it takes 2 visits and 2 weeks to get them. My secondary dentist charges just over $700 for crowns, and she scans the mouth and has a CNC machine that carves the crown out of porcelain in 6 minutes. 1 hour and I'm out the door in total. What gets me is a root canal. Our husband-wife root canal specialists charge $1,000 a root canal, up from $800. They accept cash and ATM cards only. Insurance is not accepted and they won't file papers even. I drove 40 miles to a dental surgeon and got a root canal on my BCBS insurance for far, far less. I'd just hate to think what an implant would cost. Last time our M.D. surgeons wanted almost $2250 plus $850 plus $850 to remove the tooth plus a crown would be required. Almost $5K. Ouch.

I paid $1100 for a root canal back in 2001 when I had to pay rack rate between jobs.

[mn54]

all insurance is not the same, however it is very common to have preventive covered at 100%, restorative at 80% and prosthodontics at 50%. so exams, cleanings and x-rays are covered, fillings are 80% and crowns, bridges and dentures are 50% with an annual max of $1k or $1500. You would pay based on the negotiated fee schedule the insurance has with the dentist. it is important to supply the insurance co. with all the necessary information otherwise they will reject the claim. I also would include an intra-oral photo. this oftentimes would help with the approval.

[Popeye]

Quote:

Originally Posted by Bamaman I don't know if it's my imagination, but are prices on dental services going up exponentially? My regular dentist charges $800 for crowns, and it takes 2 visits and 2 weeks to get them. My secondary dentist charges just over $700 for crowns, and she scans the mouth and has a CNC machine that carves the crown out of porcelain in 6 minutes. 1 hour and I'm out the door in total. What gets me is a root canal. Our husband-wife root canal specialists charge $1,000 a root canal, up from $800. They accept cash and ATM cards only. Insurance is not accepted and they won't file papers even. I drove 40 miles to a dental surgeon and got a root canal on my BCBS insurance for far, far less. I'd just hate to think what an implant would cost. Last time our M.D. surgeons wanted almost $2250 plus $850 plus $850 to remove the tooth plus a crown would be required. Almost $5K. Ouch.

I’m looking at an implant quote right now. I had a crown on the back molar that started feeling loose around Christmas. Of course this coincided with a COVID spike in my state so I was waiting it out. Finally went in this week between snow storms. I hoped he could just pop it off and glue it back but no such luck. The crown is now quite loose. Seems there is decay under the crown and he can’t save the tooth. I think this is the tooth I cracked about in half years ago. It may even be the second crown on the tooth.

So the plan is extraction and bone graft about $1500. Then implant and new crown about $5200 for an all in total of $6700. (They also do the same day crowns but that’s around $1500. ) They have one guy who does the bone graft surgeries and the soonest I can get in is April 1. I am on the list to call in if he gets a cancellation in the meantime.

This is a new dentist for me. My dentist of 25+ years just retired / sold the practice. The old office is still there but the dentists are all new and from online pics are about 14 years old! Lol! It sure is a move from 20th century to 21st century technology. Everything looks new. They do extensive x-rays and photos of every tooth so you can see what they are talking about. The new dentist is further out into the suburbs and is priced accordingly. They submit claims for you but aren’t in network for anyone so they charge what they want and you pay the difference. They do offer 8% cash / check discount if you pay in advance and 5% if you pay day of service. Then you get whatever insurance covers sent direct to you afterwards.

[finnski1]

Quote:

Originally Posted by Bamaman I don't know if it's my imagination, but are prices on dental services going up exponentially? My regular dentist charges $800 for crowns, and it takes 2 visits and 2 weeks to get them. My secondary dentist charges just over $700 for crowns, and she scans the mouth and has a CNC machine that carves the crown out of porcelain in 6 minutes. 1 hour and I'm out the door in total.

I would be ecstatic with a price of only $800 for a crown. Around here mine cost me $1850.

[braumeister]

Quote:

Originally Posted by finnski1 I would be ecstatic with a price of only $800 for a crown. Around here mine cost me $1850.

Yeah, that seems unusual. My dentist charges around $1,300 for a crown and he isn't considered expensive.

[John Galt III]

Quote:

Originally Posted by Montecfo I would attempt to negotiate a lower rate for the crown if it is denied by your insurance.

The total the dentist is charging is about $1,400. So the 'allowed amount' the insurance would pay is around $1,000 probably. Maybe the dentist would be OK with getting a check from me for $1,000 if the ins co does not pay.

[Amethyst]

With insurance, we've been paying around $1000 for crowns ($1600 regular rate), for a "full zirconia ceramic" crown, which supposedly is the most costly. Apparently, cheaper crown materials exist.