Wierd letter from my medical insurance

[Frylock]

I have to wait til Monday before I can call about it, so I thought I’d chat about it here.

Here’s an excerpt from the letter:

[Insurance Company] has received a request for referral from the above provider. This notice is to inform you that all or part of the referral is being approved, pended or denied. This determination was made based upon our review of the patient’s dental condition in relation to Insurance Company’s clinical guidelines, and in accordance with the terms and conditions of your Evidence of Coverage, Exclusions and Limitations:

Date Performed – (blank)
Procedure – Special Consult
Fee Charge – $35
Allowed – $35
Co Pay – $0

The requesting provider has been advised of this notice and given the opportunity t discuss this determination with [Insurance Company]'s dental reviewer.

You may obtain a copy of the actual benefit provision, limitation, guideline protocol or other similar criterion on which the denial decision was based by calling [phone number].

I can not quite tell what I am being told here. It says the letter is to inform me the request is being “approved, pended or denied.” That’s a strange thing to say. Then it seems to imply I am not responsible to pay for anything by saying the Co Pay is zero, which seems nice. But it’s not clear they’re telling me that’s how things are, or rather, that that’s how things apparently stand right now pending some kind of review. Then in the last bit, they refer to “the denial decision,” but they haven’t told me about any such “denial decision.” The use of the definite article here is confusing.

A bit more. Attached is a form filled out by the dentist we visited. It says the reason they referred us to someone else (that’s what this is about BTW) is because “Patient didn’t allow us to do X-Rays.” But that’s misleading. After sitting our three year old down in their char for about two minutes, they told us they couldn’t do X-Rays because his mouth was too small for their equipment, and they told us we needed to visit a pediatric dentist and they then referred us to someone. I don’t know whether the dentist has lied to the insurance company, or if what happens counts for legal or contractual purposes as us “not allowing” them to do X-Rays or something. And we don’t know what either of these possibilities implies for us and the balance of our checking account, either.

Anyway, I can’t figure out exactly what I’m being told in any of this. Any ideas?

-FrL-

[gardentraveler]

Ah, yes, nice clear insurance communication. :rolleyes:

It appears to me that this is something being approved because they’re including an allowed amount and stating that your co-pay will be $0.

But who know…?

[susan]

I’d call the dentist’s office. They may not have lied, but may have, oh, say, a high schooler working as a part time clerk and not typing carefully. The insurance company may be compounding the problem with their own ill-prepared or undertrained staff.