MA dental claims

[policywunk]

As the dental benefits get better on MA plans more people are using it and now i find myself dealing with dental claim problems which is the reason i stopped selling dental plans a long time ago. I have a few calls recently from disgruntled UHC MA members being denied claims for crowns. The dental code for crowns the dentist are using is a covered dental code but only if there is sign of decay. These dentist are recommending crown replacements for worn or chipped crowns with no sign of decay , not doing pre authorizations / predeterminations and the failing to tell the patients that it may not be covered according to plan benefit schedule. Then after the claim is denied tell the patient about how bad their dental insurance company is for not paying claims- and of course they will believe the dentist and not the insurance co. or the agent explaining why claim was denied. Is anybody else running in to this with MA dental plans ? Is this common with dental plans in general?

 

[Chazm]

That’s why I love UHC and Aetna. With aetnas PPO they get reimbursed $2100, and it covers anything except cosmetic.
With UHC they get $1500 and it covers anything up to the max.
Clients that I put with other companies, I warn them that it may not end up being the dental coverage you think it is.

 

[DonP]

That’s why I love UHC and Aetna. With aetnas PPO they get reimbursed $2100, and it covers anything except cosmetic.
With UHC they get $1500 and it covers anything up to the max.
Clients that I put with other companies, I warn them that it may not end up being the dental coverage you think it is.

He’s saying he’s having problems with uhc . My understanding is the dental is a bucket of money period and it covers whatever the dentist bills as long as convered expense like crowns root canals etc . I didnt know it was digging down into technical stuff like has to have decay . I tell all my clients give your ins card and make sure dentist gets Pre authorization and it’s covered . I have no doubt the Aspen dentals of the world screwing these patients up charging them big even though in network .

 

[policywunk]

He’s saying he’s having problems with uhc . My understanding is the dental is a bucket of money period and it covers whatever the dentist bills as long as convered expense like crowns root canals etc . I didnt know it was digging down into technical stuff like has to have decay . I tell all my clients give your ins card and make sure dentist gets Pre authorization and it’s covered . I have no doubt the Aspen dentals of the world screwing these patients up charging them big even though in network .

I should have clarified the claim was from 2022 it was dental code 2740 .In 2022 UHC listed all the covered dental codes in the enrollment kit. In 2023 i do not see dental codes listed only the general description of covered services listed below in EOC so i wonder if a crown replaced in 2023 for other reasons beside tooth decay( cosmetic) would be covered ? I called phd and UHC dental member service and couldn't get a direct answer.




Your UnitedHealthcare Routine Dental Benefit provides coverage for preventive and other necessary dental services such as:
Exams
Cleanings (Prophylaxis, Periodontal Maintenance, & Deep Cleanings)
Fillings
Crowns
Bridges
Root Canals
Partial Dentures
Complete Dentures
Implants

 

[Chazm]

Yeah, in 2022 they only covered certain services.

 

[LostDollar]

As the dental benefits get better on MA plans more people are using it and now i find myself dealing with dental claim problems which is the reason i stopped selling dental plans a long time ago. I have a few calls recently from disgruntled UHC MA members being denied claims for crowns. The dental code for crowns the dentist are using is a covered dental code but only if there is sign of decay. These dentist are recommending crown replacements for worn or chipped crowns with no sign of decay , not doing pre authorizations / predeterminations and the failing to tell the patients that it may not be covered according to plan benefit schedule. Then after the claim is denied tell the patient about how bad their dental insurance company is for not paying claims- and of course they will believe the dentist and not the insurance co. or the agent explaining why claim was denied. Is anybody else running in to this with MA dental plans ? Is this common with dental plans in general?

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Caveats:
I am NOT an agent.
I am a Medicare Beneficiary.
I DO NOT hold a UHC MAPD.

I DO hold an old UHC stand alone dental policy issued before UHC split their dental coverage into "under 65" and "65 and older" groups. Its coverage would approximate coverage of one of UHC's current under 65 plans with a $1,000 deductible.

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Quickly scanning my policy document, I see two things that may be relevant to your situation and may give you concepts to better frame questions for the UHC CSR's.

(Or also get one of your clients to provide you a copy of the UHC MAPD policy and then you specifically scan the dental coverage section for exclusions to see if you can pick up on something matching these general ideas.)

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One:
Services considered to be cosmetic dentistry are not covered. Crowns are specifically mentioned in that lengthy paragraph.

So crowns NOT accompanied by symptoms of decay or complaints of pain are probably considered to be cosmetic and not covered.

Two:
Replacement of crowns not placed under this UHC policy is NOT covered
UNLESS
the insured has been covered under this policy for 12 continuous months.

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My standalone UHC policy made payments in 2020 and 2021 for code 2740 crown placements.
Both were preceded by root canals for significant pain issues.

 

[LostDollar]

That’s why I love UHC and Aetna. With aetnas PPO they get reimbursed $2100, and it covers anything except cosmetic.
With UHC they get $1500 and it covers anything up to the max.
Clients that I put with other companies, I warn them that it may not end up being the dental coverage you think it is.

Key consideration for op.

 

[policywunk]

---------------------------------------------------------------------------------
Caveats:
I am NOT an agent.
I am a Medicare Beneficiary.
I DO NOT hold a UHC MAPD.

I DO hold an old UHC stand alone dental policy issued before UHC split their dental coverage into "under 65" and "65 and older" groups. Its coverage would approximate coverage of one of UHC's current under 65 plans with a $1,000 deductible.

------------------------------------------------------------------------------------

Quickly scanning my policy document, I see two things that may be relevant to your situation and may give you concepts to better frame questions for the UHC CSR's.

(Or also get one of your clients to provide you a copy of the UHC MAPD policy and then you specifically scan the dental coverage section for exclusions to see if you can pick up on something matching these general ideas.)

--------------------------------------------------------------------------------------

One:
Services considered to be cosmetic dentistry are not covered. Crowns are specifically mentioned in that lengthy paragraph.

So crowns NOT accompanied by symptoms of decay or complaints of pain are probably considered to be cosmetic and not covered.

Two:
Replacement of crowns not placed under this UHC policy is NOT covered
UNLESS
the insured has been covered under this policy for 12 continuous months.

-------------------------------------------------------------------------------------------

My standalone UHC policy made payments in 2020 and 2021 for code 2740 crown placements.
Both were preceded by root canals for significant pain issues.

I am no dental plan expert but that is what i thought how a typical dental plan would cover code 2740 .I asked my dentist office about this since i am in the process of getting a replacement crown due to decay and they confirmed code 2740 is not usually covered by insurance unless there is decay. I hope that the UHC bucket of money dental benefits is covering this but i can't find anything about dental codes foe 2023

I believe these dentist do not want to do a preauthorization before replacing a crown because they fear losing the business once the patient is told it won't be covered or even if it is covered they fear patients will lose interest in treatment plan if they have to wait 3 weeks.

 

[LostDollar]

I am no dental plan expert but that is what i thought how a typical dental plan would cover code 2740 .I asked my dentist office about this since i am in the process of getting a replacement crown due to decay and they confirmed code 2740 is not usually covered by insurance unless there is decay. I hope that the UHC bucket of money dental benefits is covering this but i can't find anything about dental codes foe 2023

I believe these dentist do not want to do a preauthorization before replacing a crown because they fear losing the business once the patient is told it won't be covered or even if it is covered they fear patients will lose interest in treatment plan if they have to wait 3 weeks.

My crown charges were accompanied by d2950 core buildup charges.

My suggestion would be to call UHC one or two times again and ask if those specific crown codes are covered when the patient has decay and pain in the tooth.

You are also likely to be charged for some xrays, I can hunt up the codes my dentist used for those if you want to ask about them as well.

 

[LostDollar]

If you need sedation, you may have to pay for that, I can't remember for sure.