ComplaintsforDelta Dental of Illinois

• Initial Complaint

  06/29/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  My dentist filed a claim for 10/26/2021. Sent in claim along with second claim for same date. Delta acknowledged receipt of 2nd (smaller) claim. Delta says they needed more info on larger claim. Dentist sent it in (x-rays included). Delta claims they cannot read xrays so dentist sent them per mail. Twice. Last time with my EOB. Now they say they never received them. I think my dentist has sent this stuff in 5 times. And they have also called and talked with the **************** line. I just want my claim paid. I should get a free month for all the time I've spent on the phone, as well as the dentist.And the last phone call some *************** up on me when I just kept repeating I wanted a supervisor - so he hung up.

  

  Business response

  07/19/2022

  July 19, 2022
  
  Customer Relations Advocate
  ********************** of ******* &Northern Illinois, Inc.                   
  330 *************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************;
  *******, Illinois 60611
  
  Re:          BBB File Number 17498336
  
  Dear Sir or Madam,
  
  On behalf of Delta Dental of Illinois,this letter serves as the response to the complaint filed by the complainant regarding their denied claim.
  
  The complainants original claim was denied because no **rays or required documentation was received with the claim.A second claim was received from the provider but denied as a duplicate claim. However,the second claim included **ray images, and our customer service team requested our consultant review the **rays to see if a determination could be made for the original claim.  The **ray images that were sent with the duplicate claim were determined by our review team to be poor quality, so a determination could not be made. A customer service representative reached back out to the provider and requested better quality images of the **rays. We received new copies of the **ray images from the provider, and the claim was adjusted to pay a specified amount due to the complainant reaching their maximum.
  
  We believe the above information responds to this complaint and concludes our handling of this matter. Should your agency need additional information, please contact **************************************

• Initial Complaint

  05/14/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I had my first Dental implant done on my tooth 30 and 31 on 5/22/21. I have never had any type of implant before. I went back to my dentist for cleaning, they surprised me with the **** of $500.00. I asked the *** Dental Group what is this **** about and they said my insurance denied the insurance claim. The reason of denial was "052 Coverage for this procedure is subject to a contractual frequency/interval limitation." I have NEVER done any time of implant on my teeth. I told *** Dental Group there might be some kind of misunderstanding. They resubmit the claim and got rejected once more. I called the delta dental myself on several occasions and inquired about it with the customer rep. I was told the claim should've been approved since I've never done any implant crown. The customer rep. agreed to resubmit the claim on my behalf. Several weeks later, I called again and found out it got denied again. I then talked to the supervisor of the customer service rep. and I was told I did crown on my teeth within last 5 years and that's why my claims were denied due to frequency/interval limitation. This is completely bogus because Implant crown is totally different from regular crown. I told the *** Dental about the situation and they said they don't have a choice but to pass on the cost to me. I negotiated and the last resolution was I had to pay $500 out of my pocket or else they will send it to the collection agency.

  

  Business response

  05/23/2022

  May 23, 2022
  
  Customer Relations Advocate
  ********************** of ******* &Northern Illinois, Inc.                 
  330 *******************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************;
  *******, Illinois 60611
  
  Re:         BBB File Number 17203108
  
  Dear Sir or Madam,
  
  On behalf of Delta Dental of Illinois,this letter serves as the response to the complaint filed by the complainant regarding the denial of a claim for their dental implant crown.
  
  The complainants initial claim was denied because the complainants policy has a frequency limitation on crowns of once every five years per tooth. It was determined the complainant had received treatment on the same tooth with a natural tooth crown less than five years ago and now received a dental implant crown on the same tooth.
  
  The complainants provider and complainant called Delta Dental of Illinois multiple times; both were informed of the reasoning for the denial. The complainant requested to speak to a supervisor who explained the decision again and advised that the complainant could appeal the decision. We reviewed the appeal, and the original decision was upheld, and the appeal denied because of the frequency of the service previously mentioned.  
  
  We believe the above information responds to this complaint and concludes our handling of this matter. Should your agency need additional information, please contact **************************************

  Customer response

  05/25/2022

  Complaint: 17203108
  

  
  I am rejecting this response because: The complainants initial claim was denied because the complainants policy has a frequency limitation on crowns of once every five years per tooth. It was determined the complainant had received treatment on the same tooth with a natural tooth crown less than five years ago and now received a dental implant crown on the same tooth.

  They did not provide me with the detail of the policy. They are stating the frequency limitation on crowns. Doesn't natural tooth crown different from implant crown? I did not have the same type of crown twice to violate the frequency limitation. I would understand it if I replace the implant crown within 5 years but mine is not the case. I had to remove the initial natural tooth crown to get implant crown. Otherwise, it'll effect my other teeth. I am very unsatisfied with the outcome.

  
  Sincerely,
  
  *****************

  

  Business response

  06/07/2022

  June 7, 2022
  
  Customer Relations Advocate
  ********************** of ******* &Northern Illinois, Inc.                   
  330 *************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************;
  *******, Illinois 60611
  
  Re:          BBB File Number 17203108
  
  Dear Sir or Madam,
  
  On behalf of Delta Dental of Illinois,this letter serves as the response to the rejection of our initial response to the complaint filed by the complainant regarding the denial of a claim for their dental implant crown.
  
  The complainants dental coverage is self-funded by their employer, which means the complainants plan benefits,including coverage and benefit limitations, are  determined by their employer, not Delta Dental of Illinois. For the complainants plan, a natural tooth crown and implant crown both fall under the same benefit category and therefore, have the same frequency limitation.  Because of this,there is still the same limitation on crowns of once every five years for the same tooth.
  
  We believe the above information responds to this complaint and concludes our handling of this matter. Should your agency need additional information, please contact **************************************

• Initial Complaint

  03/10/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  I had a ****** refund coming from Delta Dental of Illinois for a 7/7/21 dental procedure. I checked my DD account on 12/28/21 to see where they were with the claim and it showed they issued a check to me on 12/29/21 (see attachment). Of course, I found this odd since it was the 28th when I checked in; regardless, the check never arrived after several weeks. I called DD on January 26 to inform them of this. After verifying my mailing address, the customer service rep kept me on the phone while she canceled the original check and requested a new one. Several weeks passed and that check also never arrived. I called again on Feb. 21 and this time she told me that the second check was never generated because the first check was cashed on Feb. 4! How is this possible? She kept me on the phone while the first check was canceled, but someone managed to cash it a week later? Where was it cashed? Why did someone wait five weeks to cash my check when that would allow time to put a stop on it? She said I can't answer that for you. So I'm just out the ******? She said she can request a copy of the signed check and have it sent to my email in one to two weeks, so "You'll be able to tell if it's your signature." I said I already know it's not my signature because I never got the check, so what I am I supposed to do with a copy of a forged check? She said you'll have to call your bank. My bank? Why aren't they calling their bank? Her answer we didn't cash your check. Needless to say, I never received a copy of the signed check, nor did I expect to. Why did they make the check payable to me anyway, instead of the dentist, which is the normal procedure? And why didn't they send me a follow up letter explaining that the check was cashed? Something is not right. I want the ****** I have coming to me. Can you please check into this?

  

  Business response

  03/16/2022

  March 16, 2022
  
  Customer Relations Advocate
  ********************** of ******* &Northern Illinois, Inc.                 
  330 *******************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************;
  *******, Illinois 60611
  
  Re:         BBB File Number 16863801
  
  Dear Sir or Madam,
  
  On behalf of Delta Dental of Illinois,this letter serves as the response to the complaint filed by the complainant regarding reimbursement for a check following a dental visit.
  
  The complainant saw a non-network provider for treatment. With some dental plans, Delta Dental of Illinois allows assignment of benefits, meaning that a subscriber can designate for payments to be sent directly to their provider instead of themselves if the provider is non-network.However, assignment of benefits to a non-network provider was not designated on the claim form. The complainant is also a subscriber of a group plan that is self-funded, and, as such, the group funds claims payments. This group has a claims lag, which means the claim is paid once the group funds the claims payment. This claim was processed according to the lag time for this group, and the check was issued to the complainant on December 29, 2021.
  
  When the complainant called on January 26, 2022, a customer experience representative reviewed claim status in Delta Dental of Illinois processing system and saw that the check was active. The customer experience representative confirmed the subscribers address for accuracy and placed a stop/reissue request on the check that same day. The customer experience representative also sent an inquiry to our claims adjustor. On January 27, 2022, our claims adjustor responded that according to our bank, the check posted January 6, 2022. However, this information was not available in our system at the time of the call, and did not show as reconciled in our database until February 2, 2022.
  
  On February 21, 2022, the complainant called back for an update regarding reimbursement for her claim, and a customer experience representative informed the complainant that we received confirmation the check had been cashed. The complainant stated she had not cashed the check and requested a copy of the cashed check be sent to her email address. The customer experience representative placed a request to obtain a copy of the cashed check to send to the  complainant.  
  
  If the check was cashed by someone other than the complainant, the complainant can request and complete a fraud packet to start an investigation.
  
  Once the forms are received, our ****************** will send the request to our bank by certified mail to begin their investigation. This process takes time, and the reimbursement window is up to six to 12 months. Delta Dental of Illinois is not involved with the investigation, as it is strictly between our bank and the bank where the check was presented for payment.
  
  We believe the above information responds to this complaint and concludes our handling of this matter. Should your agency need additional information, please contact *************************************.

  Customer response

  03/21/2022

   
  Complaint: 16863801
  
  I am rejecting this response because:
  
  Sincerely,
  
  ***************************

  Customer response

  03/23/2022

  I could use DD's response in my rhetoric classes as examples of faulty arguments and mixed messages. I will ignore the first paragraph as it has no relevance to my complaint.
  
  Their response claims that the customer rep I spoke to on ******* saw that the check was still active and put a stop on the check, but that a claims adjuster then responded that according to Delta Dentals bank, the check posted on 1-6-21.  Why was I not sent a follow-up letter disclosing this information? (And why was the check showing as still active 21 days later?) Also, when I called again on Feb 21, the rep said that the check was cashed on 2-4-20, not 1-6-20, as claimed by the respondent.   Im sure there is a recording of this conversation for verification.
  
  What matters though, is that the respondent then further side-steps their culpability by admitting they were supposed to send me a copy of the cashed check:

  The complainant stated she had not cashed the check and requested a copy of the cashed check be sent to her email address. The customer experience representative placed a request to obtain a copy of the cashed check to send to the complainant.  
  
  Why wasnt this done? That would prove who cashed the check and at what bank and in what city. This is just another attempt to evade their liability and continue to withhold the money that I paid out-of-pocket to a provider.  Now they want to push the responsibility on me to request and complete a fraud packet to start an investigation . . . which can take up to six to 12 months. They didnt tell me this on the phone when I told them that I did not receive or cash the check. And, not surprisingly, they did not provide the details on how to get the fraud packet in their response; instead, putting more stress and work on me, nor did they account for the missing copy of the cashed check they promised to send to me via email. They couldnt get the real check, nor a copy of the cashed check to me in over three months time.
  
  I do not accept this response. Ive done my work. Ive already spent too much time on this. I began my investigation in January, 2020 and was given false information with a lack of follow-through for two months. Why did I have to contact BBB to get this company to take proper action? It is Delta Dentals responsibility to get my money to me. Consider this my fraud investigation. I have been defrauded by Delta Dental and I hope that BBB can help me get my money from this irresponsible company, beginning with the copy of the cashed check.
  
  Thank you,

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

  
  

  

  Business response

  04/04/2022

  April 4, 2022
  
  Customer Relations Advocate
  ********************** of ******* & Northern Illinois, Inc.                 
  330 *******************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************;
  *******,Illinois 60611
  
  Re:         BBB File Number 16863801
  
  Dear Sir or Madam,
  
  On behalf of Delta Dental of Illinois, this letter serves as a response to the complainants rejection of our initial response to their complaint regarding a check for claim reimbursement.
  
  We appreciate the subscribers patience as we reviewed this issue, and we want to assure the subscriber that we greatly value their feedback and take these types of issues seriously.  We always strive to provide excellent customer service and to exceed our members expectations. To provide the best customer service possible, we are reviewing our existing procedures to find where we can make improvements and prevent these types of incidents in the future.
  
  In our initial response, we responded to the subscribers first point in their complaint that referenced why we sent the check directly to them instead of their provider.Since the subscriber visited an out-of-network dentist and did not assign benefits to that dentist, we sent the check directly to the subscriber.  The subscriber also mentioned a lag in claim payment,and we explained in our initial response that the lag in payment was due to their dental plan being self-funded. Payment timing is determined by the group/employer in a self-funded dental plan.
  
  When the subscriber called on January 26, 2022, regarding payment for their claim, they informed us that they had not received the reimbursement check.  Our customer experience representative saw in our system that the check had been issued and was active.  The subscriber requested that we place a stop on the active check and re-issue the check.  At this time, we informed the subscriber that this process could take between **** business days. As part of this process, the customer experience representative sent an inquiry to our claims adjustor, and the claims adjustor contacted our bank. According to our bank, the check posted on January 6, 2022. Once a check has posted, Delta Dental of Illinois is no longer able to stop payment or re-issue the check even if a request is submitted to do so.
  
  In addition, as our finance department processes payments, there is a delay between when we receive information from our bank and when information is entered into our system. The check in question was entered as reconciled in our system by our finance department on February 2, 2022. This information was not available in our system for our customer experience representative to view when the subscriber called on January 26.
  
  The member followed up regarding their claim payment on February 21, 2022, at which time the customer experience representative discovered that the check was entered as reconciled in our system by our finance department as of February 2, 2022. The subscriber stated that they had not deposited the check and requested that we email them a copy of the deposited check.  Once we received a copy of the check, the customer experience representative emailed a copy of the check to the subscriber. A copy of the check can be re-sent to the subscriber as needed.
  
  When we received the copy of the check, we were only able to see the name of the person the check was issued to, which was the subscriber, and the bank where the check was deposited. This information was noted in the copy of the check we sent to the subscriber. The email may have inadvertently been received in the subscribers spam folder.
  
  If the subscriber disputes the deposit with the bank noted on the check copy, they can complete the attached fraud packet and return it to us to start the investigation process.  Once we receive the forms, well send the forms to our bank by certified mail, and our bank will conduct an investigation with the bank where the check was deposited.  This investigation can take between 6 12 months.  Delta Dental of Illinois is not involved with the investigation as it is strictly between our bank and the bank where the check was deposited.
  
  We understand the frustration the subscriber may have experienced with the amount of time it took to review their request and provide them with information regarding their reimbursement check. Again, Delta Dental of Illinois greatly values our members feedback and always strives to provide excellent customer service. We are reviewing our existing processes and procedures to ensure this type of incident does not recur.
  
  We believe the above information responds to the rejection of our initial response and concludes our handling of this matter. Should your agency need additional information, please contact **************************************

  Customer response

  04/05/2022

   
  Complaint: 16863801
  
  I am rejecting this response because: I just spent an hour responding and then went to post it and saw the copied checks in question. Why did they not mention the checks were included instead of saying they could send another copy to my email if required?  Regardless, there's no signature on these checks! I don't understand! They claim that I cashed the checks, but there's no signature on them! 

  My response (prior to seeing the checks) follows, but the bigger question now is, What is going on? 

  Since all of this started with Delta Dental my neurological condition, a painful muscle movement disorder called cervical dystonia, has been exponentially aggravated. After listening to a voicemail from a Delta Dental rep yesterday, and following up with a phone call to the customer service number she provided, I could not sleep from the painful twisting of my neck caused by Delta Dentals lies, discrepancies, and shockingly unprofessional behavior.
  
  Lets start with their lies and discrepancies, as evidenced in this latest DD response. They state Our customer experience representative saw in our system that the check had been issued and was active.  The subscriber requested that we place a stop on the active check and re-issue the check.  At this time, we informed the subscriber that this process could take between **** business days.
  
  It was the customer service rep who informed me that she would put a stop payment on the check and request a reissue, and she also kept me on the phone during the process of requesting the stop payment. She explained that it would take **** business days for me to receive the new check, not to put a stop on the check.
  
  They state: The subscriber stated that they had not deposited the check and requested that we email them a copy of the deposited check.  Once we received a copy of the check, the customer experience representative emailed a copy of the check to the subscriber. A copy of the check can be re-sent to the subscriber as needed.
  
  Why would they add that the check can be resent as needed? Its needed! Its already been established that I did not receive a copy of the cashed check. Its why I gave up and contacted BBB. On top of that, the person who left the voicemail yesterday, Monday, April, 4 (she conveniently did not provide a name so that there is no ability to trace the caller; i.e. no accountability) said that she sent another copy.  To add to this insult, the rep ******** C) I spoke to on the phone following that voicemail read the notes on my case out loud, including that a request was made to the ** specialist to forward a copy of the check to the (requesting) customer service rep and thats it - no follow-up note stating that the rep then sent the copy to my email. And yet, the latest written response says that it was sent (note that this was not stated in their first response). ******* C added that its unusual for ** to send the copy to the customer service rep, as they typically send it directly to the customer. Regardless, that rep never sent the copy of the cashed check to my email, and apparently there is no such copy in my files that ******* C could send to me either. She claimed that she would make a new request that a copy be sent, which I should receive in ***** hours. (Were at 30 hours presently).
  
  I then asked her to send me a fraud packet. (I had not received the latest BBB response at this time). She asked me to confirm my email again, which I did, and she sent it. I waited for it while we continued with the check fiasco, and 5 minutes later, the fraud packet still hadnt arrived. In the meantime, as I questioned the notes that she was reading, she yelled loudly Im trying to explain it if you would stop interrupting! I let you speak, now its my turn to speak! I was shocked by this outburst, but also by her inability to understand the issue.  I said, by all means, continue . . . and she went on to re-read the exact same notes that she had read prior, and which I was questioning when she lashed out.
  
  I said, we arent getting anywhere. I didnt get the original check, and I didnt get the copy of the original check. I also didnt get the fraud packet that you just sent. I then gave her another email to send it to. She said OK, but Ive been on the phone with you for 40 minutes thats too long! I am not staying on the line any longer. What about the time Ive spent on this ordeal making four phone calls and writing three letters?  And what did all that time accomplish? Nothing.
  
  The email from ******** C) did arrive to my second address, but there was nothing attached except a message. She sent me nothing! I knew immediately when I saw the attachment labeled message HTML.  HTML files are text only. You cant send a writable PDF file as HTML. I immediately replied that she sent me nothing but a message of the message, and of course, still no response.
  
  So now Ive opened the fraud packet included in their latest response (why are they just now sending this when Ive expressed that fraud clearly has been committed?), and it states
   I declare under the penalty of perjury that the below stated is true.
   ? Endorsement The endorsement on the back of the check listed above is either a forgery, is missing, or was incorrectly endorsed (can ONLY be filed by the ***** on the check). o I did not endorse the check and/or I did not authorize the endorsement.
  
  I dont have a check! I cant confirm that the signature was forged because they wont send me anything!
  
  This is outrageous. The additional stress this has caused has led my neurologist to put a hold on my deep brain stimulation surgery planned for this summer until I can get it under control. I am asking that BBB please intervene and demand that they send a copy of the cashed check to me and copy BBB.  I should not have to go through this stress and another **** months of games. I am certain they have done this to other customers as well; if they continue to drag things out, my next move will be to contact the local news investigation teams and *** Delta Dental of IL for pain and suffering. I hope that they can act professionally.
  
  Sincerely,
  
  ***************************

  

  Business response

  04/11/2022

  April 11, 2022
  
  Customer Relations Advocate
  ********************** of ******* & Northern Illinois, Inc.                 
  330 *******************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************;
  *******,Illinois 60611
  
  Re:         BBB File Number 16863801
  
  Dear Sir or Madam,
  
  On behalf of Delta Dental of Illinois, this letter serves as the response to the second rejection to our responses to the initial complaint filed by the complainant regarding reimbursement for a check following a dental visit.
  
  In response to the most recent rejection, the complainant states that we say she cashed the checks. We did not state that the complainant cashed the check, but stated the check was cashed and included information on how the complainant could proceed with a fraud investigation. 
  
  We included a copy of the cashed checks with the fraud paperwork in our last response. We apologize that the letter did not reference the checks were enclosed with the fraud paperwork. There was so signature on the check, but some banks do not require an endorsement/signature when a check is deposited into an individuals personal account versus being deposited for cash.
  
  Our bank shows that the check was deposited to a bank account, so the process now is for the complainant to complete the fraud paperwork and our bank and the bank where the check was deposited will work to resolve it.
  
  As we noted in the prior response, once we receive the fraud paperwork, we will send the forms to our bank by certified mail, and our bank will conduct an investigation with the bank where the check was deposited. This investigation can take between 6 and 12 months. Delta Dental of Illinois is not involved with the investigation as it is strictly between our bank and the bank where the check was deposited.
  
  During the investigation, the bank will review the account the check was deposited into and review the endorsement or lack of endorsement against their practices. If the bank determines that the check was deposited fraudulently, they will issue a refund to us and we will reissue payment to the complainant. We cannot reissue payment to the complainant until the bank investigation is complete and of course, any payment reissue depends on the outcome of the investigation.  
  
  We believe the above information responds to this complaint and concludes our handling of this matter. Should your agency need additional information, please contact **************************************

  Customer response

  04/18/2022

   
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution will have to be satisfactory in order for me to get on with my life. I hope that this company can become better organized, factual, and responsible in their customer service relations. It took nearly three months to get images of the checks, and when I did get them, they were stealthily added to a BBB response with no mention that they were attached in the response. In fact, the language was that they can be sent to the customer again if needed. All of the ** reps emphasized that I can see if it's my signature on the checks once they send the copies, but when I get the copies, there is no signature on the checks. Why couldn't a single person mention that as a possibility? The fraud forms also lean toward a forged signature. One of their reps screamed at me on the phone and failed to send me documents to two different emails. 

  It saddens me that my university uses Delta Dental. Do better, Delta Dental. 

  Thank you, BBB.
  
  Sincerely,
  
  ***************************

• Initial Complaint

  03/09/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  Delta Dental is our carrier for dental and orthodontic insurance through my husband's company. My son, *************************, DOB 8-14-2008 started the treatment for Phase 2 braces on 8-17-2021 with: ****************. Address: ****************************************************************** Phone: ************** At the time of the consultation for ***** at this office, we were told that ***** has a $1000 benefit remaining for braces. Delta Dental is doing everything in their power to not pay us our benefit. They have claimed that according to coding, ***** has already received Phase 2 braces which is completely not true. They asked ****************. and Central Illinois Orthodontic (************************************************************ *****) to resubmit different coding which both businesses did. I have probably made 15 calls to Delta Dental in the last few months, always to get a different person, always a different response. They have not given me any information in writing. They have not given me a denial letter but have only told me my claim is denied. It truly is the worst case of sliding doors I have ever experienced. Both Orthodonists have done everything they can, and ****************** of ****************. is trying to help by writing a letter to Delta Dental. However, we need a "denial" letter from them and haven't gone it. Not to mention that their denial is completely unfounded and wrong. They just don't want to pay and are making things up and change the rules every time we call. I have requested a transcript from DD for all of the phone conversations with all of the differing instructions on what we need to do. They change the rules every time the Orthodontists do what they tell them. I do not expect I will get a transcript from them as it will show their deceit.

  

  Business response

  03/16/2022

  March 16, 2022
  
  Customer Relations Advocate
  ********************** of ******* & Northern Illinois, Inc.                 
  330 *******************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************;
  *******,Illinois 60611
  
  Re:         BBB File Number 16856638
  
  Dear Sir or Madam,
  
  On behalf of Delta Dental of Illinois, this letter serves as the response to the complaint filed by the complainant regarding reimbursement for orthodontic claims for their covered dependent.
  
  On March 15,2016, we received a claim for Phase I orthodontics for the dependent from ****************, which was processed. On May 2, 2017, we received a claim for Phase II orthodontics for the dependent from Central ** Orthodontics, which was processed. On September 23, 2021, we received another claim for Phase II orthodontics for the dependent from ****************, which was denied because the dependent had reached the frequency limitation for this procedure according to their plan, which covers each orthodontia phase once per person per lifetime.
  
  On October 18,2021, we received a request from Central ** Orthodontics, who provided the first Phase II orthodontic treatment, to reprocess their initial claim as Phase I orthodontics instead of Phase II.  At this time, we advised Central ** Orthodontics that we would not reprocess this claim because the dependent already had Phase I orthodontics in 2016 with ****************, which would exceed the frequency limitation for this procedure under the members plan.
  
  On November 2,2021, we received a request from **************** to reprocess their initial claim for Phase I orthodontics submitted in 2016 using another procedure code.  At this time, our auditor advised **************** that reprocessing the claim under the new procedure code would not change how the claim was originally processed as it would still be considered Phase I orthodontic treatment.
  
  On March 9,2022, our auditor reviewed a corrected claim from **************** stating that their original claim submitted in 2016 should be reprocessed using procedure code D8680.  This procedure code is an orthodontic retention code versus a Phase I procedure code that was initially submitted.  We were able to reprocess this claim.  Our auditor was then able to review the claim submitted in 2017 by Central ** Orthodontics and reprocess that claim as a Phase I procedure instead of Phase II.  Consequently, the claim submitted by **************** for Phase II orthodontics on September 23, 2021, was approved and adjusted to pay the remaining orthodontia benefit. This payment will be sent to the subscriber.
  
  We believe the above information responds to this complaint and concludes our handling of this matter. Should your agency need additional information, please contact **************************************

  Customer response

  03/16/2022

   
  Complaint: 16856638
  
  I am rejecting this response because:

  While everything documented by Delta Dental in their response is correct, they have failed immensely to share the difficulty and complexity with which they required to come to this resolution. I initially called in Oct. 2021 to find out the status of our $1000 benefit and at that point was told that my son had already had Phase 2 braces and that there was nothing to be done (all of which was untrue). My son started Phase 2 orthodontic treatment in Aug 2021. After countless phone calls on my behalf since Delta Dental never once called me back to inform me of the status of all the different changes of the codes that both **************** and Central IL Orthodontics offices did as per requested by Delta Dental. I called somewhere between 15 and 20 times. Each and every time I called, I had to speak with a new customer service representative, and they would read through the previous notes and then proceed to tell me that there were additional steps that I and the Orthodontic offices had to take. We jumped through every single hoop they asked us to, even though the rules changed practically every time I called. I asked to speak to a supervisor and was connected with *****. Upon my first conversation with *****, he basically told me there was nothing more to be done, that even if I submitted an appeal, it probably wouldn't change anything and in fact, ***** only had $1000 total lifetime ortho benefits. I knew that was not true, but that ***** had $2000 worth of benefits.  ***** was, in my opinion, very dismissive to me. His response to me was very quick and it didn't even seem that he took the time to read through our case notes. He was just refusing to give us our money and all along Delta threw around medical codes knowing full well that I have no idea what they mean.  I called DD again the very day I filed this complaint with the BBB. I asked to speak with ***** again and this time, I detailed to him the months of countless phone calls I have made, how we have jumped through every hoop they threw at us. I stated that it seemed like "sliding doors" and it was pretty obvious that they were doing everything they could to not give us the money that was due to us. I believe most people would give up after having called that many times and having to also call 2 different Orthodontists' offices multiple times. I spent HOURS on the phone trying to get our benefit that we should have had last September. Not until I started demanding a transcript of all of our phone conversations as well as the "denial code" from them did we all of a sudden hear back that they were now giving us our money. In fact, I have to wonder if they suddenly changed their mind because I also threatened legal action or if it is because they received notice of this complaint against them. Regardless, I feel they should actually pay me for the hours I spent trying to get our money. I feel Delta Dental was acting deceitfully and I filed this complaint in hopes that it prevents them from treating another customer this poorly. 

  In addition, according to the Insurance/Office manager at the ******************** Delta Dental sometimes just changes codes to make things more difficult without an explanation. 

  
  Sincerely,
  
  ***************************

  

  Business response

  03/29/2022

  March 29, 2022
  
  Customer Relations Advocate
  ********************** of ******* & Northern Illinois, Inc.                 
  330 *******************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************;
  *******,Illinois 60611
  
  Re:         BBB File Number 16856638
  
  Dear Sir or Madam,
  
  On behalf of Delta Dental of Illinois, this letter serves as a response to the complainants rejection of our initial response to her complaint regarding reimbursement for orthodontic coverage.
  
  We appreciate the subscribers patience as we worked to resolve this issue, and we want to assure the subscriber that we greatly value their feedback and take these types of issues seriously.  We always strive to provide excellent customer service and to exceed our members expectations. To ensure faster resolution of these types of issues and to provide the best customer service possible, we are reviewing our existing call flows and processes to find ways where we can make improvements.
  
  We understand the frustration the subscriber may have experienced with the amount of time it took to reprocess their claim.  In our initial response to the subscribers complaint, we outlined the events that occurred to explain why claim reimbursement was delayed.
  
  As an insurance carrier, Delta Dental of Illinois is only able to provide information regarding member claims based on what we receive from the provider. We rely on the provider to submit the correct procedure code when sending us a claim for reimbursement. When we receive an incorrect procedure code on a claim, we rely on the provider to make any necessary corrections and resubmit the claim.  In this case, once we received the correct procedure codes for the claims in question, we were able to adjust and reprocess the claims to allow resolution and send the final payment to the member.
  
  Again, Delta Dental of Illinois greatly values our members feedback and always strives to provide excellent customer service. We are reviewing this specific incident in our analysis of how we can streamline our processes to ensure faster claims resolution and how we can prevent this type of incident in the future.
  
  We believe the above information responds to the rejection of our initial response and concludes our handling of this matter. Should your agency need additional information, please contact **************************************

  Customer response

  04/02/2022

   
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
  
  Sincerely,
  
  ***************************

• Initial Complaint

  01/18/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I was told I no longer have coverage from Dental Dental. I pay my premium monthly via autopay. I have NEVER missed a payment. I have been calling the customer support phone number ************** multiple times a day. I have been on hold waiting for a representative to no avial!I have submitted several emails as well.My dentist was told they could not disclose why I no longer have Dental Insurance due to HIPA laws.

  

  Business response

  01/19/2022

  January 19, 2022
  
  Customer Relations Advocate
  ********************** of ******* &Northern Illinois, Inc.                 
  ************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************************, Illinois 60611
  
  Re:        BBB Complaint 16481452
  
  To Whom It May Concern:
  
  Delta Dental of Illinois is in receipt of your correspondence regarding the above matter. Based on the information included with the correspondence, it appears that this complaint was sent to us in error and the complainant may not be a Delta Dental of Illinois subscriber. Therefore,for Delta Dental of Illinois to investigate further please provide additional information listed below.
  
  1. Copy of the members ID card (FRONT AND BACK)
  
  Your time is appreciated with this request for additional information. If the bureau has additional questions,please contact **************************************

*Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business. ↩