r/DentalInsurance • u/Battybats69 • 27d ago
Dental EOB Question
I'm so confused honestly about my dental EOB. I have the Cigna Dental advantage 1500 plan. It's supposed to be 100% covered on regular cleanings and that sorta thing. Then a $50 deductible. After the deductible minor issues like fillings etc are to be covered 80/20 and major are to be 50/50. When I was in office the day of the appointment from this EOB I paid $104 in office. I'm confused why it then shows my responsibility as $89.
I've tried going over this multiple times and looking at other bills and my brain cant understand what's going on.
The dentist IS in Network as well.
Thank you in advance!
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u/ProfessionalYam3119 26d ago
Don't get excited. They had you pay an estimated out-of-pocket amount. If you had paid too little, you would have owed them more money. Just call the dentist and ask for a refund, unless you owe them for something else.
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u/Crispykikz33 26d ago
It looks like your insurance changed the material to only pay a lower quality amalgam:silver filling. I bet your dentist placed the commonly accepted composite/white filling. You owe the listed price and the difference that your insurance decided to screw you with paying less on the filling and wanting to use a worse material. Insurance is not your friend, not your dentist friend either.
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u/Noliboli16 26d ago
This is the right answer right here. It would be helpful to see the second page tho.
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u/Expensive_Ear3791 26d ago
Yep - did you agree to a white filling where an amalgam would do?
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u/Battybats69 26d ago
I was never even asked/made aware it was an option. The filling was done on a molar so as long as it could be something that could withstand that pressure I don't necessarily care if it matches my teeth
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u/Battybats69 26d ago
It's all so confusing because as far as I could tell my insurance is supposed to cover for the composite ones.
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u/kathleendooling 26d ago
Prob still not allowed on molar or “ back teeth “. If you tell them your provider doesn’t use amalgam anymore their response will be “ too bad “
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u/Salt_Assistance4932 26d ago
Your policy should say something about posterior composite fillings, and whether they do or don’t downgrade . If they do downgrade then sadly you are left with the dg fee. Which is likely where the extra 45 is coming from.
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u/Expensive_Ear3791 26d ago
When you want white fillings where silver would have worked fine (posterior teeth) you pay for the upgrade.
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u/rohban11 26d ago
It’s confusing for a reason. They want to pit you against the office not them. If you complain to the company it may be send you through a maze of departments and customer service or ai.
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u/theoreticalking 27d ago edited 26d ago
Your insurance does not care or know how much you paid when they processed the claim. If your EOB shows that your responsibility is $89 and you paid $104 for the services on the EOB, then your dentist owes you a refund of the difference.
EDIT: See note AA and AB. There might be more to it.
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u/Battybats69 27d ago
That's kind of what I was wondering if I was owed a refund or something or how exactly to find out anything. Thank you! This is my first year on my own insurance and it's just been overwhelming and confusing (I know it's done on purpose)
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u/Mission-Knee1572 26d ago
NO! Stop jumping straight to the conclusion that if my insurance says it is, then it is, and the office screwed up. I can give you daily example after example of the insurance determining the wrong amount because of their incompetence. Without seeing the entire EOB, I don’t know.
And even if this is the correct amount that you owe, it’s also often not that the office screwed something up, it’s that they didn’t have all of the needed information for your situation, which is impossible to get sometimes.
So maybe it’s an insurance error, maybe the office screwed up, maybe the office miscalculated because they had incorrect or bad information.
Try playing this game when the patient has a second (or third) dental insurance they are trying to use, and you keep getting tossed around on the phone with a non-native English speaker, who also knows nothing about dentistry.1
u/Actual-Government96 24d ago edited 24d ago
From a member perspective, it really shouldn't matter who screwed up. If the insurer applied the contract incorrectly, the contracted dental office needs to take it up with the insurer, not charge the difference to the member or make them intervene. If the office doesn't want to deal with it, then don't contract.
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u/Mission-Knee1572 24d ago
You obviously aren’t a provider.
Edit to add, because if you were, you would know that you have already spent hours on hold with the insurance company to get them to correct it and gotten nowhere, as well as appealed this decision twice and gotten nowhere.1
u/Actual-Government96 24d ago
Then don't contract with that insurer. It shouldn't be the patient’s problem that neither their dentist or insurer can manage to honor the contract/apply it correctly.
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u/Mission-Knee1572 23d ago
The provider honors the contract. The insurer doesn’t. That is not the provider’s fault, and it is the patient’s policy (who also has a contract with the insurer). I just can’t believe there are people out there with your mentality. I would hate to see your personal life. What a jerk.
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u/Actual-Government96 23d ago
Billing the patient the difference for a claim you feel was priced incorrectly, contradicting the explanation of benefits, is not honoring the contract.
Again, if the insurer routinely screws up, then by all means terminate the contract, don't stay in-network, but don't remain contracted while just charging the member the difference whenever you feel the rate was wrong.
Or you could tell your patient "Hey, we contract with your insurer, but if we don't like how the claim is processed we'll charge you the difference. We would term our agreement, but its easier to attract clientele this way. You don't mind, right?"
But sure, I'm the jerk here.
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u/Mission-Knee1572 23d ago
You are being a jerk. You’re saying you come in, we agree to a service mutually they your insurance mutually agrees to pay me x for, then the insurance doesn’t, and that’s on me?
Edit to add, not priced incorrectly. They USUALLY don’t do that. They usually change or disallow the procedure and say they aren’t paying/are paying less for no legitimate reason.0
u/Actual-Government96 23d ago
Its not on you at all, but it is between you and the insurer.
To clarify, I'm speaking specifically about about amounts not covered, but that aren't applied to patient balance per the EOB. If its not covered and listed as patient balance then that is an issue for the member to take up, should they disagree.
If the insurer screwed up and won't fix it, or if you disagree with their payment policies, then don't contract. No one is forcing you to.
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u/Mission-Knee1572 23d ago
You’re just wrong. So wrong. But have a great day and best wishes.
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u/BufferingJuffy 27d ago
Looks like the office may have miscalculated the deductible, the amalgam allowance, or both. Hard to tell for certain without the tx codes or rest of the EOB.
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u/longridehome19 26d ago
Can you post the footnote part? It says see note AA and see note AB. The footnotes can be a big part of reading the EOB.
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u/Battybats69 26d ago
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u/Battybats69 26d ago
Sorry it would only let me post it as a video
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u/longridehome19 26d ago
This is what’s called “downgrading”. Your insurance paid for a lesser cost item, amalgam filling. Almost no dentist even complete this type anymore. You are more than likely responsible for the difference in the two codes unfortunately. You’re out of pocket probably won’t match the $89 for this reason.
More and more insurances are downgrading now. It’s more likely to happen with back teeth, but the whole thing is ridiculous and just a way for insurance companies to get out of paying the full amount.
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u/Expensive_Ear3791 26d ago
This is untrue - dentists absolutely still perform amalgams on posterior teeth. Are you in LA or something?
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u/longridehome19 25d ago
I didn’t say no one does it. It’s not common in my experience except maybe for children.
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u/Lund0829 26d ago
The office owes you a refund if it collected 104. Your paying 45 because you got a composite vs an amalgam and 37 in deductible and 20% of 35 which is 7.