ComplaintsforDelta Dental Plan of Missouri

• Initial Complaint

  09/05/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  **Complaint Statement:**I am filing a complaint regarding my ongoing issues with Delta Dental Missouri in processing a claim for dental work completed on June 23, 2024. From the start, I have been asked to provide unorthodox information to file the claim, much of which was not communicated clearly or proactively. The process to file a claim is clearly for dental offices and not for customers. Since initially filing the claim, Delta Dental has repeatedly requested additional information, causing me to resubmit the claim multiple times. Each time, there has been no direct communication informing me of what specific information is needed or why. I have only learned about these requests by reaching out to Delta Dental myself. Despite speaking to various customer service agents, I have received conflicting and incomplete guidance, leaving the claim unresolved.It has now been several months without payment, and the delay has caused me significant financial hardship. The excessive time to process my claim is unacceptable, and I am seeking immediate resolution, including clear communication regarding what is needed to finalize the claim and prompt payment for the services provided.

  

  Business response

  09/09/2024

  Delta Dental of Missouri (DDMO) records indicate support documentation was previously requested for claim #**************, date of service 6/2/2024.  Completed documentation was received by DDMO on 8/30/2024 and sent to our ***************** for review.  On 9/5/2024, the claim was reprocessed accordingly.  Payment of $1,165.00 and EOB will be issued on 9/10/2024.  

• Initial Complaint

  08/27/2024

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  Delta Dental refuses to pay valid claims. I have contacted Delta Dental several times about several of my claims being denied. The 1st claim they denied was for implant abutments and crowns that was performed on 3/18/24'and 3/29/24 which are covered under my plan. I was told the claims were being denied because of ***(Cordination of Benefits) issue and they needed my secondary insurance info(even though Delta Dental is the primary). I sent the secondary insurance on June 3 2024 via email after talking to *** on the phone. I called back several weeks later(july) after seeing my claims had still not been processed and was told that is was a *** issue. I verbally gave the the *** my secondary ins info and explained Delta Dental was my primary insurance. I was told the info would be recorded and my claims would be expedited. I call back several weeks later and was told that i had not given Delta enough time(30 days) to resolve the *** issue based on the July phone call(even though the email with the info was sent June 3) I was told once the *** issue was resolved the claims woukd be ***rocessed. It has now been over 30 days since I verbally gave Delta my other insurance info and the claims have stilled not been processed.(note email with the same info was sent June 3 2024). I called Delta Dental today(August 27) and the *** could not tell me why the claims had not been pirocessed(not her department). She was suppose to contact the supervisor of the department(processes thd clams?). Totally unacceptable that Delta Dental is dragging their feet on processing my claims after the requested info was sent over 2 months ago. Also note i had teeth cleaning earlier 2024 where Delta Dental processed that claim( same primary / secondary ins ) without a *** issue.

  

  Business response

  08/30/2024

  Delta Dental of Missouri (DDMO) records indicate ********************** had primary and secondary dental insurance coverage, through DDMO and UHC.  When claims were submitted to DDMO, they were "pending" due to lack of primary/secondary verification.  On 7/16/24, ********************** called DDMO and provided verbal confirmation that coverage had been terminated with his other carrier earlier in the year, and that DDMO was primary as of 4/1/24.  This information was relayed to our ************** at that time.  Due to an overwhelming backlog in that department, additional research hadn't been completed in order to finalize ************************** claims. On 8/27/21, ********************** contacted DDMO upset about the delay and his inquiry was escalated.  It was determined our ************** never received the Primary payer information from the Provider, in order to determine DDMO payment on claims incurred prior to UHC term date (this should have been included when claims were filed).  DDMO reached out to ************************** dental provider, requesting this information and as of this response, we are awaiting receipt.  Once we have that information, we will be able to pay and release all pending claims on file.  ********************** has been contacted and informed of this information.  We will reach out to him again once completed.  

  Customer response

  09/04/2024

  Complaint: 22202979
  
  I have reviewed the business' response and am rejecting it because:
  
  There are many things in this Bisiness response that are not true / inaccurate.

  1. I spoke to my Dental  Provider(DDS Denture and implant Solutions) today Sept 4 2024 and they have no knowledge of anyone from Delta  Dental  contacting them requesting any additonal information(prinary payer) concerning my claims. Nor are they sure about what info Delta Dental is requesting

  2. No One fromDelta Dental has contacted me and gave me an update on this issue. 

  3. Both my Dental Provider and myself have contacted Delta Dental several times about claims not being paid and never were told they needed additional info(primary payer)  The last time both of us spoke to Delta Dental was the week of 8/27/24

  4.In Delta Dental response it is very unclear why the claims have not be processed since 6/3/24(the date I sent them cordination benefits info). WAS it because of the backlog of cliams or the missing primary payer  info(whatever that is). If the primary payer info was the cause of the delay, please provide proof and a date that you contacted my Dental Provider(DDSDentures and Implant Solutions  -  ***********************; **************; MO ***** )

  As a last note, in the Business response it mentions a Mr  ********* several times. Not 100% sure who they are referring to, since my name is *********************************.

  
  Sincerely.

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

  

  Business response

  09/09/2024

  Delta Dental of Missouri (DDMO) was in communication with ********************** and his dental provider several times between 8/27/2024-9/6/2024 to try and determine Primary and Secondary coverage.  As of 9/6/2024, all COB information has been clarified with ********************** and subsequently communicated to provider, who have updated their records.  DDMO is currently awaiting corrected claim information from Provider and claims will be processed accordingly when received.  DDMO has spoken with ********************** and he has no further questions or concerns, as of this message.  

• Initial Complaint

  08/22/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I filed a grievance with Dental Dental regarding dental work previously completed on my upper and lower right. My bite has not been straight since, I have had to have one of the two crowns replaced by this previous dentist. I currently have pain on my lower right crown installed by the same previous dentist. The crown I had replaced on my upper right, had gaps to the left and right beside the neighboring teeth, as well as did not line up with the gum. The lower right there is a gap on the inside of the gum where you can fit your finger, as well as pain I am still having. I have pictures of the crown that was replaced by the new dentist with gaps and spaces in between. Delta Dental has done nothing to rectify any part of this situation for me, especially regarding a dentist who already has claims of over charging patients and reviews of this dentist completely changing patients bites in the past.

  

  Business response

  08/29/2024

  Delta Dental of Missouri (DDMO) records indicate a Quality-of-Care grievance was filed on 7/14/24 regarding ********************** recent dental treatment performed by *** ****************************** A certified dental consultant reviewed all the supporting documentation and clinical records submitted to DDMO.  A determination was made by the consultant that services rendered by *** *********************** were appropriate and were provided within the standard of care.  Based upon the outcome of the dental consultants review, no additional dental benefits are available for the services at issue in the complaint.

• Initial Complaint

  05/16/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Delta dental of MO doing business in ************** has repeatedly delayed paying justified dental claims. Most recently they have stalled for over 6 months and have now disabled my online account so I can not track and progress. They will not reply to email or website inquiries about the matter.

  

  Business response

  05/21/2024

  Good afternoon,

  Our records indicate we received the final element necessary (Primary carrier EOB) on 4/8/2024, in order to finalize your claim.  Due to an unusually high claims backlog, it simply hadn't been reprocessed yet, as claims are reviewed in order received.  Your request has been escalated, and the claim has been reprocessed; payment will be mailed out by the end of the week.  We sincerely apologize for the delay.

  The reason you were unable to retrieve information via our web portal, is because your policy was terminated 12/31/2023.  Users may only access benefit information via our website up to 90 days from date of termination.  We apologize for the inconvenience.  

   

  Thank you,

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

• Initial Complaint

  01/03/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  My coverage for delta dental includes 50% coverage on orthodontia up to a lifetime maximum of $1000. I had new retainers made at an in network provider and they refused to provide 50% coverage for this cost as they are contractually obligated to. They are not upholding their end of their coverage agreement and stealing money from customers.

  

  Business response

  01/03/2024

  Good afternoon,

  It appears a claim was submitted on 7/25/2023 for replacement retainers, which is not a covered benefit of the plan.  The claim was denied according to the policy guidelines and patient was responsible for incurred fees. 

  Attached are the EOB for the claim in question, as well as the Benefit Plan Summary, which shows Plan Exclusions on page 3. 

  If there are any additional questions, or if this inquiry is in regard to a different claim, please provide the date of service and/or specific procedures in question.

  Thank you,

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

  Customer response

  01/04/2024

  Complaint: ********
  
  Why is this list of exclusions not provided when signing up for a plan? How can trust that this document wasn't conveniently edited as a result of this complaint? 

  The information accessible to plan members per delta dental website portal only provides vague coverage information that orthodontia is included up to a $1000 lifetime maximum. However, reviewing the list of codes provided, nearly no orthodontia is actually covered by delta dental. This is a bait and switch technique that will be reported to the proper officials. 

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

  

  Business response

  01/04/2024

  Good afternoon,

  As stated on the original Explanation of Benefits, this service is not included as a contract benefit for your group.  I have attached the ******** ***** Inc. Summary Plan Description and insert, provided to ******** employees at time of enrollment on the DDMO policy.  The SPD insert states that benefits will not be paid for repair or replacement of an orthodontic appliance.  These documents are also available online through our Member portal. 

   

  Thank you,

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

  Customer response

  01/05/2024

  Complaint: ********
  
  I am rejecting this response because: It did not address anything in my previous response regarding intentionally deceptive business practices by Delta Dental of MO. Prior to receiving these services, it was verified with Delta Dental that this was covered. And instead, received a surprise bill for the full amount.

   

  These documents are not listed on their mobile portal, and simply states coverage is as I have stated in previous responses. 
  

• Initial Complaint

  12/28/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  On Dec 1, 2022, my husband started the process for dental implants. Our dental office filed a claim with my group plan with Delta. They approved and paid $2120 of the over $36000 claim. This week our dental office received a letter dated Dec 13, 2023, from Delta stating they want the $2120 returned as it was paid by mistake. This seems outrageous. Seems the company should know the coverage. The group policy (retired teacher group) dropped Delta at the end of 2022. I tried to find out why it was approved and a year later found to be an error with no satisfactory explanation.

  

  Business response

  01/26/2024

  We apologize for this inconvenience.  When your claim was processed, our system mistakenly covered some of the claim submitted by your dentist when in fact, all was your responsibility based on your plan coverage.  The services rendered were not a covered benefit under the plan you were enrolled in.  Therefore, we overpaid your dentist, and they have a right to collect the payment from you.

   

  Customer response

  01/26/2024

  Complaint: 21068613
  
  I am rejecting this response because:
  It was your job to process a claim accurately. It was not our fault and the responsibility is yours for accurate claim resolution.
  
  
  Sincerely,
  
  ****** *****

  

  Business response

  02/07/2024

  There is no further resolution to this complaint we can offer.  When the claim the customer is disputing was processed, our system mistakenly covered what was submitted by her dentist when in fact, it was the member's responsibility based on her plan coverage. Therefore, we overpaid her dentist, and they have a right to collect the payment from the patient.  

• Initial Complaint

  10/31/2023

  Complaint Type:

  Customer Service Issues

  Status:

  Answered

  More info

  I have Delta Dental of MO for my dental insurance. My dentist is no longer going to be in-network with Delta Dental on January 1, 2024. I reached out to Delta to ask how much they will pay an out of-network dentist in zip code ***** for 3 *** codes. How can I budget for my FSA/HSA card without knowing how much I will be paying out of pocket? Delta sets the maximum plan allowance for these codes, but will not share these fees with covered members. They said have my dentist send in a treatment estimate. I have to get my teeth cleaned every 3 months. Which is January 2024. It takes Delta 4-6 weeks to process an estimate. My dentist can't send the estimate until January 1, 2024. If they send it now Delta will process the claim as my dentist being in-network still.I feel Delta Dental should be transparent with what the maximum allowance fees are for its members.

  

  Business response

  11/20/2023

  Delta Dental of Missouri (DDMO) has recently responded to similar inquiries and complaints submitted by ***** and ***************************.  They have made direct inquiries to DDMO, as well as submitting requests through the labor union which provides their dental benefit plan.  The ********** have also filed a complaint with the Missouri ********** of ******** and Insurance. 
  
  DDMO has responded to all of the Felsingers direct inquiries and complaints. We have provided them with a variety of options to obtain cost estimates if they choose to get services from an out of network dental provider.  As a DDMO subscriber, ********************** can register on our website and use the Dental Cost Estimator, or he can access the independent Fair Health website for consumers.  In addition, ********************** could request his provider obtain a pre-determination of benefits prior to receiving treatment.  
  
  The Felsingers will receive optimum benefits under their dental plan if they utilize an in-network provider.  DDMO would be happy to provide them with a directory of the many participating dentists in their area.  

  Customer response

  11/20/2023

  Complaint: 20805112
  
  I am rejecting this response because:  The two options Delta says we can use to determine our out of pocket amounts do not actually provide the required information. See attached.  Having my dentist send a prior authorization takes 4-6 weeks for Delta to respond with what they will pay.  This is unacceptable since my appointment is before Delta will respond.  I don't understand why Delta refuses to provide what they pay on dental procedures.  
  
  
  
  Sincerely,
  
  *****************************

• Initial Complaint

  07/17/2023

  Complaint Type:

  Order Issues

  Status:

  Answered

  More info

  On 3/6/2023 My dental provider advised me that I needed a deep cleaning on my teeth & that before they could schedule the procedure they needed to send a pre order to Delta Dental, which covers said treatment. I have telephoned Delta Dental 3 times since March and each time they tell me that they are sending over to a supervisor and someone will call me back. In the meantime I am paying for insurance and cannot get the treatment my dentist has recommended and the health of my teeth are declining as it has almost been 6 months with no response from Delta Dental.

  

  Business response

  07/18/2023

  Dear Ms. **********,

  Thank you for your inquiry.
  We apologize for the delay in getting your treatment plan processed.  Our records show that the pre-treatment estimate was approved and returned to your dental office on July 11, 2023.
  If you have not heard from your dental office, please contact them to discuss the estimate and set up your appointment.

  Delta Dental of Missouri

   

• Initial Complaint

  01/31/2023

  Complaint Type:

  Product Issues

  Status:

  Answered

  More info

  On JULY 17 2022 I had a tooth extraction at EMERGENCY DENTAL CARE US ROSEVILLE MN. for $600.62. I gave them my insurance card but they said I would have to pay first and then they will submit my insurance info. to make a long story short, No one has paid my 600.62 back to me, my Insurance (Delta Dental) said they would pay me in full but won't because the Doctor ******* ***** was not crendentialed at the time of service. After calling both the doctors office & Delta Dental Several times over the last 6 months , i still have not been paid back. I was very patient each time I called and was very nice about it, I felt like I was getting the run around. The guy in the dentist office said he doesn't have time to be calling delta dental. and Delta dental kept saying different things to me, I asked so I am just out of Luck? and she said no but because he was credentialed it was like having my neighbor pull my tooth out so they will not pay, But I was thinking its not my fault that the doctor wasn't credential , he is now credentialed, So one time I called she said the check was on the way to the doctors office and I explained to her that they said the check was supposed to go to David, and she said she would change that in her notes, We have called several times Speaking with different people each time, and each time it looks like delta dental will take care of it and still nothing has happened. I called in mid December and the agent said she would expidite the case and take care of it and it would be taken care of by the end of December, but still nothing has happened.... I now i have word from emergency dental saying that Delta Dental should take care of this and pay me back. as this is why we pay for insurance, Please help us get the money back, I am STILL out 600$ and its ***lding interest on the credit card.

  

  Business response

  05/22/2023

  We apologize for the delay in responding while we worked with several other entities to resolve Mr. ***’s complaint.

  In July 2022 Mr. *** received services from Emergency Dental Care USA in Minnesota.  When the dental claim was received by Delta Dental of Missouri (DDMO), we were unable to process the claim as benefits could not be determined based on the provider information submitted on the claim.  Unfortunately, the dentist Mr. *** saw, was not on record in the Delta Dental Plans Association database.  Mr. ***’s claim was denied with the following explanation.

  Benefits could not be determined due to the providers tax id, license number, and/or the treatment location submitted is missing or is different from the one on file with Delta Dental.  Once the provider registration with the local Delta Dental Plan is completed a new claim will need to be submitted for benefit consideration.

   

  DDMO worked with Delta Dental of Minnesota to establish a record for Dr. ******* at the office location where services were rendered

• Initial Complaint

  12/28/2021

  Complaint Type:

  Customer Service Issues

  Status:

  Answered

  More info

  I was trying to cancel my policy with them since I now am getting coverage from my job and it doesn't make sense to pay for 2 of the same insurances. The only thing online I can do is moved out of state or died which is neither for me.

  

  Business response

  03/14/2022

  We apologize for the delay in responding.  DDMO changed the administrator responsible for responding to BBB complaints and the new administrator did not receive this complaint until January 21, 2022, after the BBB follow up was received by the previous administrator.

  On November 15, 2021, Ms. ********* contacted DDMO’s Consumer Direct team to inquire about cancelling her Individual and Family Bronze plan.  The representative explained that the policy could be terminated during the next open enrollment period, March 1st – April 15th, as that is when a member can cancel, change, or modify their plan.  The representative offered to terminate the policy at that time.

  Ms. ********* asked if it could be terminated at the time of her call.  The representative explained the policy is a twelve-month contract and can only be terminated at the end of the benefit cycle – in this situation, April 30, 2022, which is the end of her plan year.   Ms. ********* said “ok,” and the representative confirmed the policy would not auto-renew.  Ms. *********’s last day of coverage will be April 30, 2022.

  The Order Summary, provided at the time of Ms. *********’s enrollment, includes terms and conditions which state “I agree to a minimum benefit period of 12 months and for every 12 months thereafter with each successful renewal.” 

  In addition, the Master Policy issued upon enrollment, under the Outline of Coverage, explains “There is a minimum benefit period of 12 months during the initial membership period and every 12 months thereafter with each successive renewal.”

  Finally, the Master Policy, under Section II, Membership Agreement and Period F., states “The initial Membership Period begins on the Membership Effective Date and continues for 12 months. At the end of the initial 12-months of the Membership Period, and any renewal period thereafter, the Membership Period shall automatically renew for successive 12-month periods, unless coverage is earlier terminated as provided herein. During the then-current Membership Period, the Member is obligated to maintain coverage for that Membership Period of 12 months. The Member must pay all premiums due to Delta Dental for coverage during the entire Membership Period timely, even if the Member elects to discontinue coverage before such minimum 12-month period has been satisfied.”

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