ComplaintsforNortheast Delta Dental

• Initial Complaint

  04/07/2023

  Complaint Type:

  Billing Issues

  Status:

  Resolved

  More info

  We chose delta dental ppo in sept 2022 because their website listed our dentist as a ppo provider. I called several times and was told to go ahead with my routine care appointment as it would be covered at 100%. We had appointments in November and December 2022. We are now being billed for treating out of net work even though their website said our dentist was in network. Our appeal was also rejected as they stated the dentist has not been in the PPO since 2020. I feel our claims should be covered because their website gave false information to which we relied upon when choosing our plan and seeking dental treatment.

  Business response

  04/12/2023

  Re:                   Billing
  Subscriber: ***** *****
  ID:                    ********
  
  Dear Better Business Bureau:
  Thank you for sending ***** *****’s complaint to our attention. Erin H***, Director, Marketing and Communications asked that I respond to Mr. *****’s complaint.
  
  We’re unable to find a Northeast Delta Dental covered subscriber or patient named ***** *****. I left a voice mail message and email message with ****** **** asking for the names and dates of birth for the subscriber and patients, and the ID number from the patient’s ID card.
  
  Delta Dental Plan Association (DDPA) has 37 individual member companies who cover all the individual states, District of Columbia, and Puerto Rico. We recommend Ms. ***** review her declaration page for the name of the Delta Dental member company who she contracted with in 2022. If Ms. ***** is not able to locate her declaration page, we further recommend that she contact the dentist who provided treatment and ask if they can provide her with the dental insurance information for the claims in question.
  Please contact me at ************ or ********@nedelta.com with any questions regarding this complaint.

  
  Sincerely,
  Catherine C F******
  Manager, Customer Service
  
  Cc:       William L********, Senior Vice President, Operations
              Erin H***, Director, Marketing and Communications
              Robert K******* Director, Customer and Provider Services.

  Customer response

  04/17/2023

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me. I will refill with correct subsidiary.
  
  Sincerely,
  
  ***** *****

• Initial Complaint

  02/22/2022

  Complaint Type:

  Sales and Advertising Issues

  Status:

  Answered

  More info

  I have been waiting on a reimbursement check for 6+ months. I have spoke with April and now Rebecca several times with no help. Their failure-to-pay model is wrong and should be illegal.

  Business response

  03/18/2022

  Business Response /* (1000, 5, 2022/02/28) */ Contact Name and Title: ********* ******* Contact Phone: ***-***-**** Contact Email: ********@nedelta.com Re: BBB Case #: ******** Complainant: **** *** **** Subscriber ID#: ************** Dear ******* ********, Thank you for bringing Mr. **** *** ****'s complaint to our attention. Mr. *** **** has not received a reimbursement check for date of service June 24, 2021, and is requesting that this be resolved. On August 11, 2021, Northeast Delta Dental issued a check in the amount of $204.00 for date of service June 24, 2021 for an evaluation, x-rays, and cleaning. The check was returned to Northeast Delta Dental as undeliverable. The reimbursement check was then forwarded to Mr. *** ****'s employer, Emburse. Northeast Delta Dental requires all address changes to be updated by the subscriber's employer. There was no record of a request by Emburse to update Mr. *** ****'s address. On September 17, 2021 Mr. *** **** called and spoke with April in Customer Service. He asked about his check. April told him that the check was returned to us as undeliverable that the check was sent to his employer to forward to him. Mr. *** **** reported the check missing on January 18, 2022. Northeast Delta Dental completed the check research and reissued check number XXXXXXX on January 19, 2022. The check was created prior to updating our records with Mr. *** ****'s new address, therefore, the check was sent to the incorrect address. Northeast Delta Dental has updated our records with Mr. *** ****'s current address. The reimbursement check for the amount of $204.00 was reissued, and sent via United Parcel Service (UPS) next day delivery service, tracking number 1ZXXXXXXXXXXXXXXXX to Mr. *** **** at **** **** ****** ***** *********, ** *****. It was delivered to him on Friday, February 25, 2022. I apologize for our error in sending the reissued check to the incorrect address. Please contact me at ********@nedelta.com or call ***-***-**** with any questions regarding the reimbursement for check for Mr. *** ****. Sincerely, ********* *. ******* Manager, Customer Service Northeast Delta Dental Consumer Response /* (3000, 7, 2022/03/01) */ (The consumer indicated he/she DID NOT accept the response from the business.) The bill from the provider was over $450 dollars w/x-rays. The $200 check was well below the average cost of a cleaning and x-rays. I would like the remaining amount to be sent. My dental office called them and told them the amount. Business Response /* (4000, 9, 2022/03/02) */ Re: BBB Case #: ******** Complainant: **** *** **** Subscriber ID#: ************** Dear ******* ********, Please see the explanation of benefits for Mr. *** ****'s June 24, 2021 treatment. In addition, I've attached the employer, Emburse, policy and outline of coverage for your review. On June 24, 2021, Mr. *** **** received dental treatment from Dr. Anthony M. F**********, of ****** ****. Dr. F********** is not a participating dentist with Delta Dental; therefore, the subscriber may be required to pay for services at the time they are provided, and payment for treatment is limited to lesser of the submitted charge, or Delta Dental's allowance for Non-Participating Dentists in the geographic area in which services were provided. This is in accordance with Mr. *** ****'s dental policy with Northeast Delta Dental's group contract with Emburse (Group no. **********). Specifically, Section II. "How to File a Claim" of the Dental Plan Description booklet (page 7) reads, in pertinent part: Non-Participating Dentists or Other Dental Providers (ODPs): Northeast Delta Dental provides coverage regardless of your choice of Dentist or ODP, participating or not. When visiting a Non- Participating Dentist or Non-Participating ODP (who is a person, other than a Dentist, who provides Dental Care and is authorized and licensed to provide such services by the state in which the services are rendered), you may be required to submit your own claim (available at www.nedelta.com) and pay for services at the time they are provided. All claims should be submitted to Northeast Delta Dental. Payment will be made directly to you. Some states may require that assignment of benefits (directing that payment be sent to the provider) be honored. In these instances, payment will be made directly to the Non-Participating Dentist or Non-Participating ODP when written notice of such an assignment is made on the claim. In either case, payment for treatment performed by a Non-Participating Dentist or Non-Participating ODP will be limited to the lesser of the submitted charge or Delta Dental's allowance for Non-Participating Dentists or Non- Participating ODPs in the geographic area in which services were provided. It is your responsibility to make full payment to the Dentist or ODP. When there is not sufficient fee information available for a specific dental procedure, Northeast Delta Dental will determine an appropriate payment amount. You or someone in the dental office must fill in the Eligible Person information portion of the claim form. Please be sure information is complete and accurate to ensure the prompt and correct payment of your claim. Dr. F********** submitted a claim on behalf of Mr. *** **** for date of service June 24, 2021 for the following treatment: Comprehensive oral evaluation Procedure code D0150, with submitted fee of $95.00 Bitewings-four radiographic images (x-rays) Procedure code D0274, with submitted fee of $70.00 Panoramic radiographic image (x-ray) Procedure code D0330, with submitted fee of$130.00 Prophylaxis-adult (cleaning) Procedure code D1110, with submitted fee of $105.00 Northeast Delta Dental processed the claim per Northeast Delta Dental's group contract with Emburse as follows: Claim no.*************** Date of Service Procedure Submitted amt. Approved amt. Non-Participating Dentist Allowed amt NEDD Payment Patient Co-Payment Processing Policy 06/24/2021 D0510 $95.00 $95.00 $51.00 $51.00 $44.00 06/24/2021 D0274 $70.00 - - - - 165* 06/24/2021 D0330 $130.00 - - - - 165 06/24/2021 D1110 $105.00 $105.00 $59.00 $59.00 $46.00 06/24/2021 D0210 $200.00 $94.00 $94.00 $94.00 $106.00 391** Total $204.00 $196.00 *Procedure is not covered as submitted. See alternate benefit procedure. **A panoramic image with supplemental radiographic images (such as periapicals or bitewing images) taken on the same date of service by the same dentist/office is considered a complete series for benefit purposes. A participating dentist agrees not to charge any difference in the fees. Northeast Delta Dental paid 100% of the Non-Participating Dentists fee of $51.00 for the comprehensive evaluation. The bitewings-four radiographic images (x-rays), code D0274, with submitted fee of $70.00, and panoramic radiographic image (x-ray), code D0330, with submitted fee of $130.00 are not covered when provided on the same date of service, however, an alternate benefit is provided. Please see the description of coverage for radiographic images on page 9 of the Emburse Dental Plan Description booklet, reads: Coverage A Exclusions and Limitations: 7. A panoramic radiographic image, with or without supplemental radiographic images (such as periapicals, bitewings and/or occlusal), is considered a complete series for time limitations and any fee in excess of the fee for a complete series is Not Billable to the Eligible Person. Northeast Delta Dental processed the bitewings-four radiographic images (x-rays), code D0274, and panoramic radiographic image (x-ray), code D0330, as an alternate benefit procedure of an intraoral-complete series of radiographic images (x-rays), code D0210. The combined total fee for the submitted codes D0274 and D0330 was $200.00, and the Non-Participating Dentists fee for the intraoral-complete series of radiographic images (x-rays), code D0210, is $94.00. Northeast Delta Dental paid 100% of the Non-Participating Dentists fee of $94.00. Northeast Delta Dental paid 100% of the Non-Participating Dentists fee of $59.00 for the prophylaxis-adult, code D1110. Northeast Delta Dental's total liability to Dr. F********** was $204.00, and Mr. *** ****'s copayment is $196.00 Please contact me at ********@nedelta.com or call ***-***-**** with any questions regarding the reimbursement for check for Mr. *** ****. Sincerely, ********* C. F****** Manager, Customer Service Northeast Delta Dental Cc: ******** *** **** ******** W*****, Director, Marketing & Communications Erin H***, , Director, Marketing & Communications William L********, Senior Vice President, Operations.

*Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business. ↩