Cypress Dental Administrators

The subscriber/member indicated she believed her provider was short paid on her claims for cleanings and a crown with dates of service in October 2015. Our records for provider network affiliations, which are maintained by a third party, inaccurately indicated her provider at the treating dental...

office location was in-network and her provider was paid correctly based on that information. However, upon notification of this complaint, we investigated with that third party the nature of this provider's network affiliation and it was determined this provider is out-of-network. As a result, we reprocessed the subscriber's claims today, 1/19/2016, for both dates of service in question providing the proper additional payment of $240.57 (a total now of $333.77) for her October 1st date of service as well as an additional $343.66 (a total of now $718.36) for her October 29th date of service including the crown procedure indicated. Both payments were mailed today to her provider which will result in a payment to her to reimburse her for Cypress' portion of the procedures she previously paid up front in full to her provider.

Review: I made an initial visit to [redacted] at [redacted] on October 1, 2015 for an exam, cleaning(prophylaxis), and x-Rays. I showed the staff my dental insurance card and they called the number on the card for Cypress Dental Administrators( [redacted]) to confirm that the location was Non-Network so they could give me an estimate of what I would pay. I had previously checked the dental network website, which did not show Dr [redacted] in network at [redacted] 91786. I entered the zip code in the search box and did not see his information in the results. I made a second visit to [redacted] to get a crown, for which I paid $1490 upfront. Per the Dental Benefit Summary provided by Cypress Dental Administrators, I expected to get a reimbursement of 50% for the crown, or $745. Both claims were processed and all I am receiving is $99. Cypress Dental Administrators claims that the dentist is in network because he has an office at [redacted] 92337 that is in network for them. I spoke with [redacted] at Cypress Dental Administrators and she sent me a screenshot that supposedly shows Dr ** is in network and should have charged me far less. The screenshot shows his name, no address, and does not list PPO, which is the type of dental insurance I have. It shows EPO and FDH networks covered. Today, I called the number for [redacted] and spoke to a representative named [redacted], that confirmed Dr. **'s [redacted] is not In Network, therefore, I should have been reimbursed 50%. It has been very frustrating to deal with Cypress Dental Administrators, the Dental Claim paperwork was mailed three times, and they claimed they didn't receive anything the first 2 times. I have spoken to several representatives over the months of November, December, and January to even get to the point of getting the claim processed.Desired Settlement: I would like to get a refund of the additional $644 due to me.

Business

Response:

The subscriber/member indicated she believed her provider was short paid on her claims for cleanings and a crown with dates of service in October 2015. Our records for provider network affiliations, which are maintained by a third party, inaccurately indicated her provider at the treating dental office location was in-network and her provider was paid correctly based on that information. However, upon notification of this complaint, we investigated with that third party the nature of this provider's network affiliation and it was determined this provider is out-of-network. As a result, we reprocessed the subscriber's claims today, 1/19/2016, for both dates of service in question providing the proper additional payment of $240.57 (a total now of $333.77) for her October 1st date of service as well as an additional $343.66 (a total of now $718.36) for her October 29th date of service including the crown procedure indicated. Both payments were mailed today to her provider which will result in a payment to her to reimburse her for Cypress' portion of the procedures she previously paid up front in full to her provider.