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Goodness - your poor son - it sounds really traumatic and painful for him.

I don't know much about insurance, so the following idea might not be possible for you, but there have been several threads here in the past few months that talked about asking for the cash rate from a health provider, because often it's much, much cheaper than any rate the provider would charge an insurance company, and often the whole "cash" charge is cheaper than the deductible and co-pay that the insured party would have been charged by the insurance company. Apparently, after you pay a cash rate, you can get a particular type of detailed statement and receipt for the medical procedure and cash transaction, and still turn those in to your insurance company, if there is any reason why that would be advantageous (to have them apply it towards your plan's annual deductible, for example, if they would allow that). There are several online newspaper articles (one was in the L.A. Times, I recall) and internet sites (one is by a practicing M.D. who is fed up with our country's insurance system) about doing this.

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Oops, I've re-read your OP and it seems they told you to have the work done by the provider and then lodge an appeal, so if you agreed to that and are at the appeal-writing stage, I guess the paying-cash idea is not possible now.

Maybe they consider it cosmetic. try to find a "medical" reason for the braces... such as jaw pain or TMJ. Possible the medical side of insurance might pick up the expense.

This wasn't a car accident, was it?
Is car insurance secondary with medical insurance primary?
Then shouldn't car insurance pick up the difference?

Or maybe the sort of accident your homeowners would cover?

rblakenyc said:   Also, the accident really was his own fault or at least enough so that not worth taking anyone to court.As much as I hate to say it, there must be some deep pocket that is at least partly to blame. You might really want to talk to someone with personal injury claim experience.

OP,

How this plays out may depend a little on what state you are in.

In addition to filing an appeal, I would file a complaint with your state's department of insurance regulation (or equivalent title, they vary by state).

In your appeal and complaint, make sure you include a copy of the approval for use of an out of network provider. I would go back and read that approval document very carefully to see what it says about benefit level.

You won't find what you need here, but rather you need to start searching to see what the law says in your state. Your state may have a law that is clear on the matter and provides a better framework for how to write your appeal/complaint letter.

Go back and find your plan summary document. Find the section that addresses use of out of network providers when an in network provider is unavailable. There should be a section and it should address the process and benefit level. This could also be used as a reference in your complaint/appeal letter.

I have not had to deal with this situation before, so I am merely outlining the strategy I would use to begin dealing with it.

I am going to guess that the term the insurance is going to use is "reasonable charges" and they may argue that the orthodontist's charges were unreasonable. If your approval specifically identified the provider you used, you have a good chance to compel the insurance company to cover the full amount billed (minus copays or deductibles).

In the meantime, you may want to actually review the claims submitted with the orthodontist. Make sure they used accurate diagnostic codes on the claims (as opposed to the most common codes they may default to).

Good Luck.

It's common for dental insurance plans to only cover 50% of services after meeting the deductible. That's the way mine is, although routine preventive care and diagnostics are covered 100% without a deductible. Maybe that's where they're getting the 50% from?

BocephusSTL said:   It's common for dental insurance plans to only cover 50% of services after meeting the deductible. That's the way mine is, although routine preventive care and diagnostics are covered 100% without a deductible. Maybe that's where they're getting the 50% from?

OP said that this is a medical insurance claim stemming from an accident. This is not a dental claim. This is essentially restoration, not cosmetic.

gatzdon said:   BocephusSTL said:   It's common for dental insurance plans to only cover 50% of services after meeting the deductible. That's the way mine is, although routine preventive care and diagnostics are covered 100% without a deductible. Maybe that's where they're getting the 50% from?

OP said that this is a medical insurance claim stemming from an accident. This is not a dental claim. This is essentially restoration, not cosmetic.

I know he said it's a medical insurance claim. He wants to know why they will only pay 90% of 50% of the orthodontics charges. I am suggesting that 50% may be a common dental insurance payout level, and since his insurer doesn't handle dental perhaps they are just using an industry standard of 50% as the basis for their payout.

And we're suggesting that OP should be pursuing it as an accident claim from the other party. Not as a medical or dental claim

ellory said:   And we're suggesting that OP should be pursuing it as an accident claim from the other party. Not as a medical or dental claim

Except it sound like OP's son was the cause of the accident...

To bring this to conclusion: I needed to file an appeal after the work was completed. I did and they approved the appeal! I got my full 90% after deductable - worth fighting for the $3,400
!

did he try to eat a M80?? for petes sake!!

rblakenyc said:   To bring this to conclusion: I needed to file an appeal after the work was completed. I did and they approved the appeal! I got my full 90% after deductable - worth fighting for the $3,400!


That's great!

Thanks for returning to your thread and completing the story - so many folks don't do that.

To those with enduring curiosity about the cause of his injury, The injury was sustained from a fall from a ski lift to hard frozen ground and rocks. Thankfully a helmet protected his head but his jaw and teeth absorbed a tremendous blow. It is unclear exactly what happened regarding the lift bar but it appears the lift had stopped somewhat near the instructions to lift the bar and he and his companion were sitting there for at least a few moments with the bar up when he fell. Happily, he is well on his way to recovery and now the latest insurance expense is covered. Hopefully he will not require implants for his lost and broken teeth as i do not think those are covered.



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