What happens when ortho becomes out-of-network while treatment is in progress?

[Ravenclaw]

I started my orthodontic treatment way back in June 2017. Back then my orthodontist was an in-network provider for my dental insurance. At the start of treatment, I paid my copay of $2,450.00. That's the total of the portion I was responsible for. The insurance company, on the other hand, would pay their share of the fee to the orthodontic office every three months. My insurance covers 24 full months of orthodontic treatment, and the contract I signed with the office also indicated that treatment would be for 24 months. Beginning this year, my ortho was no longer an in-network provider. I got an EOB from the insurance company showing they did not pay the claim that my ortho submitted last month, and I may be responsible for paying the amount billed.

When I called the insurance company, they told me that I may be responsible for the remaining balance, since the ortho is now out-of-network. It just seems a little unfair, since that ortho was in-network when I started. I asked them if I could instead go to my ortho's other office, which was still in-network. They told me they still wouldn't cover it because they would only pay if the orthodontic visits were done in the same office where I started my treatment. So even if I go to an in-network provider, they'd still not cover the remaining months! That's just patently unfair.

The representative I spoke with said they would look into it to see if they could make an exception, since there's basically a couple of payments left to make. Hopefully, the insurance company will decide to pay up.

Have any of you experienced something similar to this? If so, how did it go?

[kplatt2010]

Hey There- I've not had any experience having to fight it out with dental; it's usually medical side that I've had to jump through the hoops.

Depending on how much is the remaining balance; you might want to consider a formal appeal. Your dental insurance should have a guide which tells you all of the steps that you must do in order to appeal. In my experience with the medical; they had a 30 day turnaround.

Good Luck,
Karla

[Ravenclaw]

Hey There- I've not had any experience having to fight it out with dental; it's usually medical side that I've had to jump through the hoops.

Depending on how much is the remaining balance; you might want to consider a formal appeal. Your dental insurance should have a guide which tells you all of the steps that you must do in order to appeal. In my experience with the medical; they had a 30 day turnaround.

Good Luck,
Karla

Thanks for your suggestion. The customer service representative said he'd start a case for my issue. If they rule against paying my current ortho for the remaining months, I'd definitely research the process for sending a formal appeal. I have Blue Shield of California for my dental, and they've been great for the most part, so I'm hopeful that things will get resolved.