ComplaintsforEnvolve Dental Of Florida, Inc.

• Initial Complaint

  10/23/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  ON 11-11-2022 WE SUBMITTED MEMBER REIMBURSEMENT DENTAL CLAIM FORM AND NEVER HEARD BACK FROM ENVOLVED. ON 3-1-2023 WE SUBMITTED PAPERWORK AFTER BEING TOLD THAT WE WERE MISSING A FEW PAGES. THEN ENVOLVE TELL US THAT OUR PAPERWORK WAS IN CORRECT BECAUSE IT HAD THE WRONG CODE. SO, WE SUBMITTED NEW PAPERWORK ON 8-7-2023 WITH THE CORRECT CODE. NOW ENVOLVED IS TELLING US THAT THEY DON'T EXCEPT HANDWRITTEN RECEIPT. THEY OWE US $2,310.00

  Business response

  10/27/2023

  Hello,
  
  Thank you for the opportunity to assist with *****************************.
  
  The members current benefit plan is as follows:
  
  GA-WellCare No Premium Open (PPO)
  Eligibility Period
  3/1/2022-8/31/2023
  Annual Maximum Benefit Allowance 2022
  $1,000
  Remaining Annual Maximum Benefit Allowance 2022
  $712.50
  Coinsurance
  20% INN
  50% ONN
  
  Envolve Dental (ENVD) has the following claims on file indicating the member was reimbursed for services rendered.
  
  Claim # **************
  DOS: 10/19/2022
  D5611 Repair Resin Partial Denture Base, Mandibular (paid on another claim)
  D7210 Surgical Removal of Erupted Tooth (tooth #2)
  Total amount reimbursed to member: $250
  10/19/2023
  Check # *******
  Claim # **************
  DOS 10/19/2023
  D5611 Repair Resin Partial Denture Base, Mandibular
  Total amount reimbursed to member: $37.50
  8/24/2023
  Check # *******
  Claim # **************
  DOS 1/20/2023
  D1110 Prophylaxis Adult
  Total amount reimbursed to member: $16
  Check # *******
  
  Claim #  20230814290156
  DOS 1/20/2023
  D1110 Prophylaxis Adult
  Total amount reimbursed to member: $34
  Check # *******
  
  
  Outreach was conducted to Mid-******************** at ************** where I spoke with ******* to whom I provided member demographics and grievance details.  ******* stated the following:
  
  Provider is an OON provider with GA-WellCare
  Patient was advised prior to services being rendered
  Patient was seen on DOS 11/11/2022 where the following services were rendered:
  D0140 Limited oral evaluation - problem focused
  D0220 Intraoral - Periapical First Radiographic Image
  D5225 Intraoral - Periapical First Radiographic Image
  D5226 Intraoral - Periapical First Radiographic Image
  Patient paid OOP for services rendered in the amount of $2,060
  ******* stated she would email the claim directly to ENVD in the effort to allow review and appropriate reimbursement to be completed for the patient. ******* confirmed, all of the services listed above have been rendered and paid with nothing outstanding or left owing by the patient. 
  
  ENVD will process the member reimbursement form for services rendered on 11/11/2022 for the allowed amount minus 50% coinsurance up to her remaining Annual Maximum Benefit Allowance ($712.50) for benefit year, 2022. Please allow **** business days for the process to be complete and payment to be issued directly to the member.
  
  On 10/27/2023 at 9:55am, outreach was conducted to ***************************** at ************** where I was able to speak with the member and her husband directly.  The member was advised of the information above and that ENVD will complete the reimbursement form for payment consideration of the allowed amount up to her remaining maximum benefit allowance ($712.50)minus 50% coinsurance in reference to services rendered on 11/11/2022.  The Newmans and myself discussed the additional reimbursement checks that have been issued and discovered the following have not been received:
  
  Check # *******, Check Amount: $250, Date Issued: 10/19/2023
  Date of Service: 10/19/2022
  Service Rendered: D7210 Surgical Removal of Erupted Tooth (tooth #2)
  Check # *******, Check Amount: $16, Date Issued: 10/19/2023
  Date of Service: 1/20/2023
  Service Rendered: D1110 Prophylaxis Adult
  Check # *******, Check Amount: $34, Date Issued: 8/24/2023
  Date of Service: 1/20/2023
  Service Rendered: D1110 Prophylaxis Adult
  
  Member confirmed they did receive the following check:
  
  Check # *******, Check Amount: $37.50, Date Issued: 8/24/2023
  Date of Service: 10/19/2022
  Service Rendered: D5611 Repair Resin Partial Denture Base, Mandibular
  
  Mr. & **************** agreed to allow additional time, until Wednesday, November 1st,in the effort to receive the checks that were issued on 10/19/2023.  Additional outreach will be conducted by ENVD on Wednesday, November 1st, to the Newmans to confirm receipt; however,if they have not received the checks ENVD will place a stop payment and have them reissued.  My direct office number was provided should they require further assistance on this matter and I was thanked for my time and assistance.  Please let us know if additional information is needed.

• Initial Complaint

  07/11/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Unable to find a Dentist/Oral Surgeon that is a participating provider.

  Business response

  07/11/2023

  Good Afternoon,

  Please see the attached documents in reference to the BBB complaint filed by **************************  
  

  Thank you-

  *********************

   

  Customer response

  07/11/2023

   
  Complaint: 20301910
  
  I am rejecting this response because: The email sent to BBB is not the same as the email sent to my email address ***************** I also specifically request to be contacted via text to my phone number ********** as I cannot accept phone calls while I am at work Monday through Thursday 8am-8pm. Emails cannot always be checked until after 8pm. I have left requests for information from most of the dentists on the list that was sent to my email address.
  
  Sincerely,
  
  *************************

• Initial Complaint

  02/01/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  There is a faulty list of Envolve Dental network providers for both endodontics and oral surgeons. I have called more than I can count and I get rejected. They all say that they do not accept Envolve Dental Insurance. I have called Envolve several times without resolution. I need an endodontist and I want to use my insurance. Envolve is not providing any specialist within 50 miles.

  Business response

  02/23/2023

  
  2/22/2023
  
  Re: ***********************
  714 *************.
  ***************, **,32092
  Tel: ************
  
  Hello ******,
  
  Thank you for the opportunity to assist with ************************  Per call history, **************** reached out to Envolve Dental (ENVD) **************** (**) three times on 1/17/2023 to locate a periodontist/endodontist/oral surgeon and was provided with several options.  On the third call, **************** expressed her frustration stating that even though a number of the providers given to her in prior calls were participating and were accepting members, the offices were either further away than she wanted to drive or told her they did not accept her insurance.  The ** representative thought the member would be better served by being transferred back to the Health Plan to request a Single Case Agreement.  This representative is currently being coached as this issue should have been escalated to a ** Team Leader. 
  
  The member reached back out to ** on 2/7/2023 requesting additional assistance.  With the member on the line, one location that had been verified as participating, advised they would need to do a head CT scan. **************** declined to schedule, as this is not a covered service, and she would have had to pay approximately $350 out-of-pocket.  Again with **************** on the line, ** secured an appointment for 2/10/2023 with ******************* located at *******************************************************************************, ************.  ** followed up with the member on 2/21/2023 who stated the office cancelled the appointment as they do not accept Ambetter;however, she no longer needed assistance as she had an appointment scheduled for 3/9/2023 with another provider.  ******************* participation with Ambetter was verified at time of scheduling; however,G&A followed up with ******* at the practice who stated that after the appointment was scheduled, they were informed that the provider is no longer accepting this benefit plan.  This information has been forwarded internally to ensure our system is updated.
  
  ENVDs *************** Team has made multiple calls to **************** to follow up on her need for a provider; however, has reached her voicemail at each attempt.  Requests to have their call returned have gone unanswered.   On 2/22/2023 at 11:34 am, I reached out to the member at ************ where voicemail was reached.  A message was left for *************** extending my apologies on behalf of ENVD for any inconvenience caused.  My direct telephone number was left advising her to reach out to me should she require assistance in locating a provider to meet her dental needs.    Please let us know if additional information is needed. 
  
  Kind Regards,
  
  ***************************
  Lead Grievances & Appeals Coordinator, Quality Improvement
  Envolve Dental
  ************

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