Sunday 11th of November 2018 07:15:01 AM
Delta Dental Insurance refuses to correct miscoded claim of a partial denture although they are aware that this code is incorrect and the Dentist office admitted on April 3, 2018 that they did not give me the more expensive metal frame partial that was coded. The miscode is to Delta Dental’s advantage because it prevents me from getting any other service to the upper arch.Bay Ridge Management Corp., Cosmetic & Implant center, ** located at 7708nFourth Ave., Brooklyn NY 11209 sent Delta Dental Insurance claim#** using code D5213 on 9/08/2014. Maxillary partial denture- cast metal framework with resin denture bases (including any conventional clasps, rests and teeth). ** knows that this does not describe my partial. Mine has no metal and seems to be made entirely of nylon or acrylic-vinyl material made for only one side of the arch. My current dentist states the partial ** made for teeth 3,4,5 is a Nesbit. The correct code for the Nesbit provided me by Cosmetic & Implant Center is D1520 (space maintainer- removable – unilateral) only on one side of the arch.Delta Dental states that they already paid ** of Bay Ridge Management Corporation $750. July 28, 2017 I received a letter from Delta Dental states I had to ask the dentist to correct the code. I requested them to change it to the correct code a year ago. On April 3, 2018, they finally answered my BBB complaint stating that they gave me a more conservative less expensive partial with no metal (The Nesbit).I was not aware of the problem with the code until on or about June 1 2017, when I received a pretreatment denial Claim ** for my damaged bridge for teeth 12,3,14 on the opposite side of the arch. Which says I am responsible for the entire $2250 instead of %50 or $1125. I have been fighting this decision ever since. I had to pay the entire balance of the $2250 for replacement of the damaged bridge on teeth 12, 13, 14 which was completed Oct 20, 2017. Cosmetic & Implant center, **, D.D.S & Associates or Delta Dental Insurance Company need to correct the code so Delta Dental Ins can approve the claim and reimburse me $1125 paid by me that should have been paid by Delta Dental.DELTA DENTAL DENTIST HANDBOOK states under Prosthodontics- Removable codes (D5000-D5899) 19: Placement of a removable partial denture and a fixed bridge for the same arch will not be considered for benefit allowance. Use of a code using these numbers is the problem. Its use will cause me not to be able to file a future or current claim on the same arch. I believe this is the reason Delta Dental will not change the code to the correct code of D1520.After my present dentist sent in claim for my bridge on teeth 12,13,&14, I once again requested Delta Dental to pay that claim. Claim ** for the completed bridge was denied. I received a letter from Delta Dental dated June 1, 2018 telling me they have no jurisdiction over Dr. ** of Bay Ridge Management Corporation because they are a non-member. (Even though they corrected other issues and gone after other money owed by this company when it’s in their favor.) **, who is a member, is the original dentist that was working on this partial. He made such a mass ordering a horrible partial with the metal that would not fit my mouth instead of the Nesbit I had originally asked for.