Itemized statement from medical provider

[LennyNY]

Jurisdiction

New York

Hello,
I went to dentist specialist for procedure (TMJ). I have dental insurance, that DDS, is actually on the plan, but he does not accept insurance? for that procedure. His condition everything out of pocket, and I will deal with insurance on my own. I agreed, paid. I submitted claim to insurance, DDS gave me procedure codes and TOTAL for whole thing. Insurance called me, to check on some details, and asked me to itemized statement. I asked DDS to give me itemized statement for insurance, his office refused, same they did with insurance rep. who called and asked same question. Rep. was shocked, first of all, rep. told me that that DDS is on contract with them and should follow agreed price etc..., and rep. was shocked that DDS office refused to itemized. Is it even legal in NY to refuse statement request from patient? Also, on DDS agreement printed:
**I am aware my dental/and or medical insurance does not cover TMJ treatment my signature to this form acknowledges my agreement to have TMJ treatment and I know it will not be covered by my insurance plan** . Even my insurance covers it, and DDS, since he is plan provider, also knows that.
I paid in full for treatment out of pocket, but with all this insurance claim, I don't feel that DDS is "kosher", and how can I demand itemized statement from DDS, procedure cost thousands, I'm just trying return something from insurance.

Thanks

 

[army judge]

Is it even legal in NY to refuse statement request from patient?

It might be easier if you signed an authorization to allow the insurer to request whatever materials they require DIRECTLY from the dentist.

Ask one of the customer service reps if that would be possible.

I paid in full for treatment out of pocket, but with all this insurance claim, I don't feel that DDS is "kosher", and how can I demand itemized statement from DDS, procedure cost thousands, I'm just trying return something from insurance.

Your insurer has the ability to obtain any document they require, if you agree to it in writing.

Ask one of the customer service reps what their procedure is for you to authorize them to seek ALL documents necessary to support your claim for any approved dental procedure you paid the dentist out of pocket.

Otherwise, you can pore through the online documentation and the procedure is probably buried somewhere in that massive stack of online materials.

Forget the legalities at this point and focus on the insurer's ESTABLISHED processes, protocols, and procedures.

 

[doucar]

Before any major dental procedure,I always ask my dentist to contact my insurance company any itemized procedure request to determine what my insurance company will pay and what my share would be. Without that, and if my dentist were in network for my insurance and he insisted I pay and seek reimbursement from my insurance, I would walk out the door and find a more ethical dentist.

 

[doucar]

I don't know why it printed 3X

 

[doucar]

test

 

[LennyNY]

Before any major dental procedure, I always ask my dentist to contact my insurance company any itemized procedure request to determine what my insurance company will pay and what my share would be. Without that, and if my dentist were in network for my insurance and he insisted I pay and seek reimbursement from my insurance, I would walk out the door and find a more ethical dentist.

It was only 2 specialist in my area, both of them my insurance providers, and both of them for that procedure take only out of pocket payments. Believe me, I tried. I'm not looking for 100% reimbursement, but maybe 10%-20%. I just needed itemized statement, which I was denied by provider.

 

[cbg]

Contact your insurance company. Do not talk to Claims or Customer Service. Contact the department that deals with the dentist's contracts - it will be called Provider Relations or something on that order. Tell them what is happening. It is their job to deal with the dentist refusing to accept payment as outlined in the contract.

 

[LennyNY]

Contact your insurance company. Do not talk to Claims or Customer Service. Contact the department that deals with the dentist's contracts - it will be called Provider Relations or something on that order. Tell them what is happening. It is their job to deal with the dentist refusing to accept payment as outlined in the contract.

It's already in process. Thank you

 

[LennyNY]

Update:
Doc called me last week, TOLD me call my insurance and close grievance case (claim), other way he is going to sabotage claim, by providing them code which ins company would not be able to process, in other words, I will get zero. Then ins company call me yesterday, told me same thing, doc is not cooperating, providing them medical codes, which they can not process, so they requested notes and transcripts from doc, what work he did on me, and they own dental consultant will determine correct codes... All my explanation to doc, that I did not open grievance case to complain on him, went into space. Case end up in grievance, because last correction was sent outside date range. And only action of his front desk person, refusal to insurance provide itemized statement, cause his name(office) being on notice. Whole thing is cover by my insurance, that what was bothering ins rep. Why contracted provider, refused accept insurance.