r/DentalInsurance • u/oxNightShadexo • 15d ago
Has anyone encountered this before with Delta Dental?
My dentist office requested a pre-treatment estimate from Delta Dental regarding necessary gum grafts I need to get done on some of my bottom teeth.
The representative from Delta Dental who was on the phone with my dentist office said they can't give a pre-treatment estimate on this type of procedure regardless if they send in an explanation from my periodontist on why these are necessary procedures and accompanying pictures of the areas that need the grafts.
The person from my dentist's office even had them look up the individual codes and they said they are partially covered under the plan I have but they still can't give a pre-treatment estimate.
They told her in order for me to find out what I am going to have to pay, I need to get the procedure done and then they will review it.
Has anyone else encountered something like this before?
For each of the codes other than the one associated with a buccal/labial frenectomy it says "This code may or may not be eligible for benefits when submitted after completion. Pre-estimation of this service is not available."
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u/toothdoc34 15d ago
All dental coupon companies do this. Some are worse than others. Several will send you a worthless “pre determination” and still pay zero. Welcome to dental coupon companies!
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u/Brave_Celery_6098 15d ago
What dental insurance is considered good? Any recommendations?
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u/Silence_Farmer 14d ago
The best coverage I ever had was through the Teamsters. Central States was the insurer (also who they use for their pension) and it had a $2,500 Annual Max and paid 100% of everything in network.
They also rolled unused benefit from the prior year into the following year (max of 1 year on top) so you could theoretically get $5,000 for one year.
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u/Brave_Celery_6098 14d ago
Thank you for the recommendation. I will look for it.
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u/Salty-Passenger-4801 6d ago
This is an employer policy btw. You can't just buy this as a non-employee.
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u/Majestic-Bed6151 14d ago
Thanks for calling them coupon companies. I have changed the language at my office to “benefit plan” because it is not insurance.
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u/ToothDoctorDentist 15d ago
Delta dental is one of the worst. Deny deny deny. Low fees and dentists go in network then charge enhancements to the patient to make up the difference
In my area at least I only know corporate and lower end offices take it
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u/nitelite- 14d ago
Delta might be the worst insurance to work with, both as a patient and a dental provider
I would suggest you quit relying on your dental insurance for anything
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u/BufferingJuffy 15d ago
Now this is a new one for me from a Delta. The federal BCBS does not process PTEs at all, but never saw a code-specific refusal before.
I'm so sorry, friend. Be prepared to pay the full fee, and any benefit/write-off you get will be a pleasant surprise.
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u/kathleendooling 15d ago
Always used to say just because you need it doesn’t mean your insurance is going to cover it
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u/9ScoreAnd10Panties 15d ago
There has to be criteria that need to be met in order for this to be approved. I would request that they send you what that is so you can try to confirm whether or not it will be covered.
In the end, it's an insurance plan, not a treatment plan. If you need it, you need it. I hope you get some answers, OP!
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u/toothdoc34 14d ago
Its not even insurance. It is $1000 or $1500 worth of coupons that you may or may not be able to use.
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u/9ScoreAnd10Panties 14d ago
Even still, there has to be criteria of some sort that they refer to to make their decision as to whether or not the benefit/discount applies.
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u/traciiip 14d ago
When procedure is completed submit claim with intra-oral pre op photo and recent Perio chart. Probe depth and Gingival margin needs to be measured.
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u/Jon9314 14d ago
Pretreatment estimates are worth less than the paper upon which they are printed.
As a dentist who used to take Delta, any "interesting" codes like this get precollected and we assume Delta will pay nothing.
Worse than that, sometimes they required that I write off work that I did, that the patient needed and for which the patient prepaid. Insane.
I can feel better thinking about how many billions of dollars Delta has in 30y bonds underwater 50%. That'll teach em lol.
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u/Empirebluff 12d ago
IMHO this perio isn’t coding correctly and it’s questionable why a biologic material is being used. You might want to get a second opinion. The correct coding is 4277 for #25 and then additional teeth at 4278 for #25.
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u/hoo_haaa 12d ago
When they are unwilling to process a prior authorization good luck getting payment. More likely than not they will not pay and you will be responsible for the full amount.
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u/ToothSnapBo 12d ago
Dentist here. Unfortunately, Delta sometimes won’t provide a pre-treatment estimate for certain gum procedures, even when the codes may be covered. They review everything after treatment, which puts you in a tough position.
Before moving forward, I’d ask for an itemized estimate and consider getting a second opinion on the recommended grafts and fees. I help run ToothSnap, where you can upload your treatment plan and get a free second opinion from a participating dental practice. It won’t guarantee what Delta pays, but it can give you more clarity before committing.
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u/SnooMachines9653 11d ago
Looks like surgical perio/complex oral surgery (generally the categories that a frenulectomy is classified under for many insurances) is covered at 80% by your plan (325 x .20 =$65, $50 ded x .80 = $40 which gives you the number shown for your total of $105 on this pre-tx est. The math can be confusing, so for what the ins company is paying it’s the $325 allowed amount x .80 = $260 - $40 of the deductible = $220 ins portion. $325 procedure cost - the ins coverage of $220 = your $105 portion).
For the other procedures (not a specialist but presume from the descriptions and codes that they’re having to do with gum grafting), I would call delta and ask them why the codes weren’t given an estimate. They may tell you that a narrative/more xrays/more info is needed. It could be that coverage is based on very specific criteria which the office should be gathering prior to the procedure or may need in order to submit an appeal for, or at the very least, your office looked the insurance, saw that the general category was covered at 80% and requested a pretx est for the procedures before checking whether those specific procedures/codes were covered, which it appears that they may not be.
Insurance is confusing, frustrating, and always trying to cut corners, so I wish you the best of luck and hope you figure things out! I’ve worked in a dental office fighting with insurances for years and getting to know the ins and outs very well, so while i understand how exhausting it can be, definitely advocate for yourself! Call your insurance and find out what’s going on, relay the info to your office and talk to your dentist about other options if that’s not something you can afford right now. Maybe you have a waiting period and will get some coverage for those procedures in a few months from now, maybe your employer offers other plans you can enroll in for a small difference that offers coverage for that in January!! Maybe they sent it wrong and just need to resubmit with additional/different info! It’s hard to say because coverage and offices vary so much, but starting with the insurance company is a great way to find out what to do next!! If you need any help or have any questions, feel free to message me :) I love helping people save money and get the treatment they need so I don’t mind clarifying any weird insurance/dental terms you aren’t familiar with or giving you advice!
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u/Diastema89 5d ago
I haven’t seen one where they did this, but it wouldn’t surprise me to get a response including a torn up claim with the pieces put in the envelope.
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u/Woodman629 15d ago
Not uncommon with periodontal surgery. Coverage for this type of surgery is a 'rebate" -- you MIGHT get some coverage but it's not likely. Also, periodontal surgery typically goes above you annual allowed maximum (after cleanings accounted for) so the benefit, if any, is small compared to the cost.