Business ProfileforMolina Healthcare of Michigan Inc.

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I am writing this letter in response to the rejection of my reimbursement request for dental services. Upon review of the decision, I strongly disagree and wish to dispute it. A copy of the grievance letter is enclosed for reference.

On January 31, 2024 I made an emergency visit to my general dentist for sudden and constant oral pain. My bite was adjusted, and I was advised to return if the pain endured.

On February 6, 2024 I returned to my general dentist as an emergency status for increased and continued pain and I was informed at that time I would need an emergency referral to an endodontist for a possible root canal procedure. I received a written referral from my participating dentist, to **** ******** ************ ***** ****** *** ***** ******* *** ****** **************

Immediately after my dental appointment on February 6, 2024, I searched the Molina website for a participating endodontist to ensure my covered benefit (root canal) would apply without issue. Without success on the website (as some links appeared broken), I called Molina to speak with a representative. I explained the situation then was transferred to a different department. (Which I later found out I was transferred to **********). The ********** representative attempted to locate a participating provider on her computer but she said that her website was not working correctly. I was advised she would place an "urgent request" for a "different department" to locate a participating provider for me, and that I should be contacted within "15 days".

On February 14, 2024, while still in relentless excruciating pain for more than two weeks at this point, and requiring pain medicine around the clock, I called ********** again as I had received no contact since my last call. I spoke with ****** who informed me that my case would be "upgraded to an emergency status" and that I should hear back in 24-28 hours. I _again logged into the patient website in an attempt to self- resolve the issue without luck as there was still error messages and no Michigan participating providers listed.

On February 22, 2024, in agonizing pain and with zero contact from the insurance company, I had an emergency root canal performed at **** ******** ************, which my participating dentist (****** ****** ******) referred me to. Because *** does not participate with **********, they refused to bill the insurance directly. Payment in full is required on the day of service so it was necessary that I borrow money and pay the rest on my credit card. The grand total I paid to *** was $1,580.00 (A receipt is enclosed for reference).

On February 23, 2024, I called ********** and spoke to *****. After explaining my entire situation, she confirmed that I have 100% coverage for crowns, but couldn't assist much more than that because I had already paid for my procedure. She then transferred me to a supervisor named *****. I reiterated to him the need for the emergency root canal as I'd been patiently and diligently attempting to work.with the insurance company regarding this with zero effort on behalf of Molina and ********** all while in extreme pain for almost a month. ***** said it appears that the insurance company dropped the ball and did not competently handle my issue. ***** assured me he would open a grievance on my behalf, and that I should receive correspondence within 14 days. (Reference number for this 38-minute-long call is ************).

On April 3,2024, I finally receive a call from "******" with "Access to Care" (I am still unaware of what or who this company is), almost two months after my initial insurance inquiry. I informed her that I required an emergency root canal and am still awaiting results from a grievance I had opened. She said she would close my case but I would need to call member services in regards to any updates about my grievance. She also informed me that grievances may take up to 60 days, not the 14 days which ***** advised me of.

On April 10, 2024, I received the Grievance Resolution Letter which informed me that Molina's "records do not show a request for reimbursement for services." And that _NONPAR providers require prior authorizations.

A Root canal is removal of inflamed and/or infected pulp from the inside of a tooth. It constitutes as a dental emergency and requires prompt treatment. Not only is it excruciatingly painful, but if left untreated or delayed, it can lead to bacterial infection, bone loss, tooth loss, and sepsis. These also increase the costs of dental and medical procedures.

According to my Molina covered benefits, crowns are to be covered i00%. I diligently tried to locate a participating provider on the patient website, to no avail, as well as with multiple calls to the insurance company prior to my procedure. When the pain became unbearable, I followed my participating dentists' advice and had the root canal performed, with a provider they recommended. What good is a covered benefit, if locating a participating provider in a timely manner is near impossible for the patient as well as with the insurance company itself?

I sincerely hope this is a rare occurrence between a patient and_an insurance provider, but I am asking you to please reconsider your decision in regards to this.

I believe that my claim should be approved as soon as possible, and I wish to be reimbursed the

$1580.00 so I can put this unfortunate incident behind me and pay off the debts from this. Thank you for your prompt attention to this matter.