Worst Claim Story- December 2017
Claim that finally got paid!! It only took 16 months
By Kimberly Scharfenberg
Both Becky Osgood and myself worked on getting this paid.
On 9/29/15 a claim for BU’s for teeth number 6,7,8,9,10,11 and crowns for teeth number 7 and 10 was sent to Delta Dental. On 11/17/15 we received a partial payment of 431.00 for crown #10. We sent an appeal and it was denied. We sent another appeal with additional information and it was denied. Spoke to Delta Dental on 3/14/16 and they said that since the two appeals were denied that they would not look at another appeal. At this point we got the patient involved and drafted and sent a letter that the patient signed disputing the decision on 3/15/16. Called Delta on 5/16/16 still denied. 9/26/16 spoke to a rep at Delta and asked if we had any other recourse to get this paid. We were told we could request a consultant review with Dr. Del(fictitious name). So we sent a letter requesting the consultant to call Dr. Del to discuss the treatment completed. 8/9/16 Spoke to Delta again. They said they received the letter and a consultant would be calling Dr. Del Tuesday or Thursday of the following week. No call. 8/18/16 called Delta and they said they had sent the claim to a second consultant and they would call Dr. Del the following week. 9/7/16 Still no call. Spoke to another rep and she said she had forwarded the claim to the other consultant and had expected them to call Dr. Del this week but since that did not happen she sent it back through marked “urgent”. 10/21/16 Dr. Del finally got a call from the consultant and he said that in order to get this paid we needed to resubmit the claim with BU’s and crowns for teeth 7 and 10 and 5 surface resins for 6,8, 9 and 11. So we fixed the claim and faxed it to Delta. 11/10/16 Called to check on progress of the claim. Now we were being told that the claim was being denied due to timely filing. Spoke to a rep and explained the situation and she said she would put it back through for payment. 12/6/16 Still no payment. Called and spoke to a rep. Still trying to get us for timely filing. She looked everything over again and sent it back through. 12/20/16 Spoke to a rep and she told me that the claim was still being denied due to timely filing. Apparently, the consultant that Dr. Del had spoken to was saying that the claim was being denied due to timely filing. Enough is enough. I asked to speak to a supervisor and he looked into it and assured me that he would get this resolved before the end of the year. Finally, after all of this, we received a payment of 449.00 on 1/3/17. We would have received more but the patient’s max had been met in 2015.
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