dental claims denial bc OON with Blue Shield Dental CA hmo
Hello, has anyone any tips, suggestions on this situation. Blue Cross Anthem Ca Dental HMO?
1st time using it, had a PCP already assigned but couldn’t get a hold of them for a routine cleaning appointment. Logged into anthem portal, saw another dentist listed as “in network” so I went with them. Also, tried changing my PCP online to them.
Went to their office, they took insurance card, didn’t say anything wrong. Got my cleaning/preventative done. Got a printout of the cost sheet where shows what I’d owe for the cleaning ($0 because insurance would cover) and then other optional procedures showed some insurance coverage. Ended up getting a crown done a couple days later.
Fast forward a week. I logged into anthem portal week later and see both claims were denied for dentist being “Out of network.” It showed I owned a few thousand for both procedures.
Called customer service who basically said it’s out of network because I didn’t see PCP, and that made no sense to me BC they were listed in the portal with the words “in network dental plan” right next to them! She filed an escalation and recommended I file a formal written appeal too, which I did via mail. NO new correspondence so far. I’m just waiting.
So what happens now if they deny? Or what should I do now while I’m waiting, should I ask the dentist to fight it? Technically, I have not gotten any new bills yet in mail or otherwise. I did pay partial amount of what I was told I owe for the crown on that day I got it done.
What are my best chances of winning? In my written appeal I included screenshots of the website showing the dentist was labeled as in-network along with the print-outs showing what they said insurance would cover.
