| The article below by Greg Margulies of Pacific Group Agencies, Inc. appeared in the August NETWORK. Pacific Group Agencies, Inc. administers the insurance plans such as dental and vision that RESDC offers to members. Please note that dental enrollment is limited to an Open Enrollment period in the fall, or within 60 days of a qualifying event. You will receive a packet from RESDC in the mail once open enrollment begins this year, typically in October, and plans are effective January 2018. All other insurance plans offered through RESDC and administered by Pacific Group Agencies are typically available for enrollment year-round. Medical plans are offered only through SDCERA, not RESDC.
As the Administrator for the RESDC dental insurance plans, this is one of the most common questions we hear. Unfortunately, many people instantly assume that the reason their claim is denied is because the insurance company is greedy and does everything it can to not pay out legitimate claims. While it is easy to view the faceless insurance company as the villain, the reality is that insurance companies strive to pay claims accurately, rather than face the wrath of the Department of Insurance. Some of the most common reasons a claim is not paid when first submitted are: The Dreaded Missing Tooth Clause
Insurance is purchased to cover the risk of potential future events. Your house may burn down or you may get in a car accident. You purchase insurance for risks that may happen in the future. The same is true for dental insurance. You may need an implant or bridge. Most people who have a missing tooth intend to have it replaced with either an implant or a bridge and the insurance companies are fully aware of this. Therefore, it is standard throughout the industry that they will only cover the implant or bridge if the tooth was lost after your insurance started. Insurance covers potential future events. It covers issue that arise after your insurance started, not before. This is not to say that you cannot still receive benefits from insurance if you have a tooth that was missing before your insurance started. Using an Ameritas PPO in-network dentist may allow you to save around 30%-40% off the regular procedure rates, even if the insurance is not covering that procedure. If you are enrolled in the Cigna HMO plan, many of their network dentists will offer significant discounts on non-covered procedures. The I Have To Wait How Long Clause
Most dental procedures that fall under the Major Services category (ex. crowns, dentures, implants) have limits as to how often you can have them performed. For example, under the Ameritas plan, a crown will not be replaced on the same tooth more than once per ten year period. The reality is that modern crowns, implants, and dentures should last a long time - a lot longer than 10 years. While it is possible for them to fail earlier due to things like excessive clenching or grinding, it is rare. Early failure is often the result of poor dental workmanship. In these cases, the insurance company rightfully expects the original dentist to fix the issue at no cost to the patient. After all, if a mechanic didn’t fix your car properly the first, you’d bring it back to them and expect them to fix it at no additional cost. The dental office should be no different. The My Dentist Didn’t Submit What Issue
Insurance companies require additional support from the dentist for certain procedures. Most often it is as simple as including an x-ray or a notation on the claim form as to when a prior procedure was originally performed. If a claim is submitted without the necessary back-up information, the insurance company will send the both the patient and the dentist a request for it. Unfortunately, dentists are good at dentistry, not insurance, and many times they overlook this. If you receive notice that the insurance company is in need of additional information before they can process your claim, call your dental office ASAP to make sure they are aware of this and ask them to submit the requested information. Whenever you have a claim denied or the insurance company paid less than you expected, it is very important to read the explanation of benefits that they mail you. Many people overlook the explanation written below the payment information. If you feel that a claim was unfairly denied or paid incorrectly, we suggest you call the insurance company and ask for an explanation. If after speaking with them, you still feel you have not received a satisfactory explanation, please call our office at (800) 511-9065 and we may be able to assist. | 
