I got my wisdom teeth out a couple weeks ago and received my EOB. While looking it over there is about a $600 difference from my pre-treatment estimate to my EOB and after talking to my insurance it is because on my pre-treatment they marked the extractions as D7210 but on the post-treatment EOB they marked it as D7140 so my sedation was denied as it was seen as not necessary for the 7140 (80% coverage on the pre-treatment estimate). Had I known it would have been denied for the removal type, I wouldn’t have gotten the sedation. If my provider doesn’t change the code to reflect the 7210, is there anything I can do to get the sedation covered or am I just SOL?

Dental office plans to do some gum removal, no stitches involved and done same day, prior to my crown procedure. And yet they are billing the procedure as a D4249 "crown lengthening of hard tissue," so the insurance is denying any payment, because per their dental consultant "there is sufficient bone to support the crown." Dentist told me the same, and that he is only removing some gum. I have inquired into this, but they tell me that is just the code they use. They want to charge $1400 for this out of pocket, as my insurance won't cover any of it. Am I missing something here? It feels like fraudulent billing.

14k for 1 root canal, 2 extractions with bone graft and extensive cleaning. Only 9k with their $119 yearly membership thing they mention.

Should I get insurance? Would they even cover anything since there won’t be a waiting period?

Thanks.

Would be grateful for people to not scoff and laugh. Genuinely want to know the answer and I can't be the only one who does.

Back round. I am not the policy holder, my husband is. A month ago I create an account on metlife dental to look up who we can see for dentists and it worked! I had full access and found the information I needed (my husband gets flustered when it comes to health insurance and so I took on the duty!). Fast forward to today, I wanted to confirm provider information and look up a dentist recommendation from a friend. And lo and behold, my portal was blank/no way to look up dentists in network. I contact customer service twice and was told both times that I have to go through the main policy holder account. Someone explain to me why, that as a grown adult, I can't have my own account and have to go through the primary holder account (again, not my own). This infuriated me and I need to come down off my rage wagon. Thanks y'all.

Hello everyone.

As you can see in the title, I have a Delta Dental DeltaCare USA HMO plan for my child. We recently went in for a dental consultation because my child (3.5 years old) has some dental issues.

The dentist recommended IV sedation in-office because my child is not cooperative, and they were not able to complete X-rays during this visit. The plan is to do IV sedation at the next visit. So once the child is asleep, they will take X-rays and then complete the necessary dental procedures during the same appointment.

At this time, the dentist was only able to provide an estimate for extraction of four teeth, which is about $265 with insurance. She said those teeth are likely non-restorable and must come out. However, any additional treatment (such as more extractions or crowns) will depend on the X-rays taken during sedation.

The anesthesia fee is separate. It is not covered by dental insurance and must be paid out-of-pocket directly to the anesthesia provider (PDAA), since they do not accept insurance.

My main question is regarding the insurance benefit. My child’s plan shows a $450 out-of-pocket maximum. My understanding was that no matter how much the dental work costs (for example, $800 or more), we would only be responsible for up to $450 if the services are covered.

I called a DeltaCare representative, and they confirmed that once the out-of-pocket maximum is reached, insurance would cover 100% of covered services. However, when I asked the dental office billing department about this, they told me it works differently from medical insurance. They said that even if costs go above $450, I may still be responsible for additional charges depending on the treatment, and insurance may only cover a portion.

I’m trying to understand which explanation is correct and how the $450 out-of-pocket maximum actually applies in this situation. Thank you.

https://preview.redd.it/h5osopv8162h1.png?width=1470&format=png&auto=webp&s=b5c6f009c235adc43c80c75574260c1cbeade901

Hello everyone,

I’m feeling incredibly frustrated and hoping to get some insight or advice from anyone who has dealt with this.

I have a DeltaCare HMO plan. I have been to two different in-network dental clinics that I assigned as my primary facilities, and both offices are pulling what feels like a massive bait-and-switch scheme to avoid honoring the plan's contracted rates.

The Crown Issue

Every office I visit gives me some arbitrary reason claiming that a porcelain/ceramic crown is "not covered" and that I have to pay out-of-pocket to "upgrade" it. However, according to DeltaCare and the physical benefits manual I received (complete with CDT codes and exact copays), these crowns are fully covered under a specific copay. By forcing these "upgrades," the offices are tacking on thousands in unnecessary out-of-pocket costs.

The Root Canal & "Uncovered" Codes

The same thing is happening with a root canal. They are intentionally adding extra, non-covered CDT codes to the treatment plan just to make me pay additional money out-of-pocket.

To put the numbers into perspective:

• I went to an out-of-network dental office just to get a second opinion out-of-pocket. Using standard, necessary codes, they quoted me around $10k, offered a $4k discount, bringing the total to $6k.
• Under my actual HMO plan, those exact same standard codes should only cost me $1.7k in total copays.
• Instead, my in-network HMO offices are adding so many "upgrades" and extra codes that they are driving my HMO total up to almost $4k.

The Prior Authorization Lie

When I questioned them, the office staff claimed they submitted a prior authorization request to DeltaCare on the exact day of my visit. However, when I log into my insurance portal, I can see they only submitted a request for the office visit code—they completely left off the requests for the crowns and the root canal.

It is incredibly frustrating that these in-network offices refuse to honor the insurance contract and are actively manipulating codes to extract more money from patients.

My questions for the group:

1. Has anyone successfully fought back against an HMO dentist doing this?
2. Should I report this directly to DeltaCare as a grievance or billing fraud?
3. How can I find an HMO dentist who will actually just charge the exact copays listed in my manual without inventing "mandatory upgrades"?

Thanks in advance for any help.

First time poster and new to understand dental bills and stuff. My spouse had an upper wisdom tooth pulled by a regular dentist last month and we just received a bill that has the code 7220 on it. I tried calling the billing department of that office and they were telling me that the code is surgical related. The dentist didnt make and cuts in my spouses gums or bones and the tooth was pulled out whole (they wanted it so we have it at home... yuck). My insurance denied to cover the removal and the dental office has been of no help to explain anything. I just want to know if there is anything I can do before paying the remainder out of pocked of about $500. Thank you to anyone trying to help me understand this mess.

I recently got dental insurance so I established myself with a brand new dentist. I called to ask if they were in network and they said they would check. A bit later they called back and said they were in network. I then scheduled appointments for my 3 family members and myself and we all had a great first visit with the dentist. Today I got a bill totaling $447 for all four of us just for our semiannual cleaning and checkup. (All healthy teeth no cavities or interventions needed)

Turns out that the dentist is not in network and never was?!? They also claimed to have confirmed the insurance yet billed for special X-rays that are not covered under my plan.

How do I fight this? I feel like we have been scammed by this dentist.

I went for a root canal with an in-network dentist under Delta Dental PPO. During my first visit, the front desk verbally told me my total costs would be around $250–300.

I started the procedure there, but after the second visit I had to move to another state. I completed the root canal with a different provider, where I paid about $250 total. At this stage, I called my previous provider about this that I am having pain and need to go to visit a local provider here as I do not plan to visit the other state in near future. Also from my first two visit experience I was not satisfied with the service. They were insisting me to come back.

Now the first provider has sent me a bill/settlement notice for $800+. When I checked the EOB from Delta Dental, I noticed they billed using a random code (D3999) which has most of the charges.

I called the Dentist office multiple times and tried to dispute it, but they keep insisting I have to pay.

This amount is huge for me. What are my options here? Any advice would be appreciated.

EDIT: I had plenty of unused maximum this is last year
They tried to charge D3330 first which I questioned and then they charged me on D3999. Looks like my insurance didn't pay anything for these codes.

EDIT2: I am happy to pay Dentist 1, max for root cancal on cost estimate shows me 180USD and they said it will be around 250-300 USD max. I am not asking to not to pay Dentist 1 but rather to pay what it should have been not $$$

EDIT3: My insurance paid over $800 to them already, this $800+ which I owe is extra. I see a lot of comments on Dentist 1 should be paid, and they have paid, but they want more looks like.

I would like to figure out best dental insurance if I want to have cleaning twice a year. Also want to know how much will it cost hypothetically for plaque removal.

I live in Charlotte, North Carolina. Would love if any clinics are also recommended.

Thanks in advance for the help.

Has anyone with Fidelis Medicaid NY gotten coverage for: dental implant, sinus lift, and bone graft for a missing top second molar. I’m especially wondering if it was fully covered, required prior authorization, or was denied as “cosmetic.” Any experiences appreciated. TIA.