Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to provide additional payment for the crown and root canal provided May 5, 2021. We decided that the Plan does not have to provide additional payment for the comprehensive oral exam, bitewing x-rays, panoramic x-ray, dental cleaning, and root canal provided April 7, 2021, to April 19, 2021 and the prefabricated posts and cores, crowns and root canals provided May 10, 2021, to July 21, 2021.

You asked the Plan to provide additional payment for the comprehensive oral exam, bitewing x-rays, panoramic x-ray, dental cleaning, root canals, crowns and prefabricated posts and cores. You say that you were advised that this provider was in-network. The Plan says that the claims have processed correctly.

We decided that the Plan has to provide additional payment for the crown and root canal provided May 5, 2021.

We looked at this physician's review, the file, and Medicare rules. In this case the Plan explains in the case file that the enrollee's representative was informed on February 23, 2021, that the provider at issue was an in-network provider. The enrollee's representative was later advised by the Plan on May 21, 2021, that the provider was no longer in network effective February 28, 2021. Therefore, the enrollee's claims should be processed as in-network with this provider until May 21, 2021, when notice was given of the Plan's incorrect information regarding network status. The claims provided May 5, 2021, are covered services and were processed as OON. Therefore, we decided that the Plan has to reprocess the crown and root canal provided May 5, 2021 and provide additional payment according to the Plan's in-network coverage rules, up to the $1,500 comprehensive dental allowance.

We also decided that the Plan does not have to provide additional payment for the comprehensive oral exam, bitewing x-rays, panoramic x-ray, dental cleaning, and root canal provided April 7, 2021, to April 19, 2021 and the prefabricated posts and cores, crowns and root canals provided May 10, 2021, to July 21, 2021.

We looked at the file and Medicare rules. In this case the comprehensive exam, bitewing x-rays, panoramic x-ray and dental cleaning provided April 7, 2021, have correctly processed with a $0 in-network copayment. The root canal provided April 19, 2021, was processed correctly with 20% coinsurance according to in-network rules. The prefabricated posts and cores provided May 10, 2021, to July 12, 2021, are not covered under the enrollee's benefits. The root canals and crowns provided June 7, 2021, to July 21, 2021 have correctly processed with 80% coinsurance according to OON coverage rules. Additionally, the enrollee is responsible for the difference between the allowed amount for the services and the total cost billed by an OON provider. Therefore, we decided that the Plan does not have to provide additional payment for the comprehensive oral exam, bitewing x-rays, panoramic x-ray, dental cleaning, and root canal provided April 7, 2021, to April 19, 2021 and the prefabricated posts and cores, crowns and root canals provided May 10, 2021, to July 21, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review.

The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.