Delta Dental of Illinois

Case ID [redacted] On behalf of Delta Dental of Illinois (“DDIL”), this will serve to respond to the complaint filed by [redacted] regarding the policy she obtained through the Marketplace It is our understanding that such programs are risk policies The following will set forth our handling of this matterDDIL received two claims for Ms [redacted] from Dr [redacted] DDIL covers 100% of the allowed amount for Preventive services after satisfaction of the $deductibleClaim [redacted] for date of service 08/06/was billed for Prophylaxis (procedure code ***) and Comprehensive Oral evaluation (procedure code 150)The approved amount for code [redacted] is $and the allowed amount is $49.00, DDIL covered $The approved amount for code Dis $and the allowed amount is $38.00, DDIL covered $after the $deductibleThe member’s deductible and the difference between the approved amount and the allowed amount is the member’s responsibility which is $A check for $including the Explanation of Payment was sent to the provider and the Explanation of Benefits was sent to the member on 08/19/ Claim [redacted] for date of service 02/10/was billed for Prophylaxis (procedure code ***) and Periodic Oral evaluation (procedure code 120) The approved amount for code [redacted] is $and the allowed amount is $49.00, DDIL covered $ The approved amount for code Dis $and the allowed amount is $25.00, DDIL covered $The difference between the approved amount and the allowed amount is the member’s responsibility which is $Check for $including the Explanation of Payment was sent to the provider and Explanation of Benefits was sent to the member on 03/02/ Please note that Dr [redacted] is a Premier providerA dentist participating in the DDIL Premier network is obligated to accept the lesser of the Dentist submitted amount or the Maximum Plan allowance as full payment for services coveredThe member is responsible for the applicable Deductible and patient co-payment amount, plus the difference between the approved amount and the allowed amountWe believe the claims were processed correctly We believe the above information responds to this complaint and concludes our handling of this matterIf you have any questions, please contact me at [redacted] @deltadentalil.com or [redacted]

On behalf of Delta Dental of Illinois (“DDIL”), this will serve to respond to the rebuttal by *** *** regarding the policy she obtained through the Marketplace Ms*** mentioned in her rebuttal that DDIL failed to inform her of the network dentists that she can seeHowever, our records show that the member contacted DDIL on several occasions, before and after the services were billed, wherein she was advised that the plan pays at the PPO fee tableOn 06/29/2015, the member was advised that the plan pays at the PPO fee table, the Customer Service Representative (“CSR”) sent a list of PPO providers to memberOn 06/30/2015, a different CSR provided the member with a list of phone numbers of PPO Providers in her areaAfter the date of service of claim, the member was advised on at least two separate occasions by two different CSRs that the plan pays at the PPO fee tableOn 03/15/2015, the member called stating that she was given a list of providers which shows the billing provider, Dr*** *** as par, member was advised that “par means Premier." On 03/24/and 03/25/2016, a supervisor left a voice mail to member asking her to fax over the provider listing that she received from us to confirm if Dr*** *** shows as PPO on the list Our records show that Mr*** was given PPO provider numbers and a list of PPO providers in her areaWe have not received a response from the member We believe the above information responds to this complaint and concludes our handling of this matterIf you have any questions, please contact me at ***@deltadentalil.com or *** Sincerely, Carolyn MShanahan Director, Compliance

Case ID [redacted] On behalf of Delta Dental of Illinois (“DDIL”), this will serve to respond to the complaint filed by [redacted] regarding the policy she obtained through the Marketplace.  It is our understanding that such programs are risk policies.  The following will set...

forth our handling of this matter. DDIL received two claims for Ms. [redacted] from Dr. [redacted]. DDIL covers 100% of the allowed amount for Preventive services after satisfaction of the $25.00 deductible. Claim [redacted] for date of service 08/06/2015 was billed for Prophylaxis (procedure code [redacted])  and Comprehensive Oral evaluation (procedure code 150). The approved amount for code [redacted] is $78.00 and the allowed amount is $49.00, DDIL covered $49.00 The approved amount for code D0150 is $69.00 and the allowed amount is $38.00, DDIL covered $13.00 after the $25.00 deductible. The member’s deductible and the difference between the approved amount and the allowed amount is the member’s responsibility which is $85.00. A check for $62.00 including the Explanation of Payment was sent to the provider and the Explanation of Benefits was sent to the member on 08/19/2015.   Claim [redacted] for date of service 02/10/2016 was billed for Prophylaxis (procedure code [redacted])  and Periodic Oral evaluation (procedure code 120).  The approved amount for code [redacted] is $78.00 and the allowed amount is $49.00, DDIL covered $49.00  The approved amount for code D0120 is $41.00 and the allowed amount is $25.00, DDIL covered $25.00 The difference between the approved amount and the allowed amount is the member’s responsibility which is $45.00 Check for $74.00 including the Explanation of Payment was sent to the provider and Explanation of Benefits was sent to the member on 03/02/2016.   Please note that Dr. [redacted] is a Premier provider. A dentist participating in the DDIL Premier network is obligated to accept the lesser of the Dentist submitted amount or the Maximum Plan allowance as full payment for services covered. The member is responsible for the applicable Deductible and patient co-payment amount, plus the difference between the approved amount and the allowed amount. We believe the claims were processed correctly.    We believe the above information responds to this complaint and concludes our handling of this matter. If you have any questions, please contact me at [redacted]@deltadentalil.com or [redacted]

Complaint: [redacted]
I am rejecting this response because:
Sincerely,
[redacted] DELTA DENTAL FAILED TO INFORM ME AS THE CUSTOMER ABOUT NETWORK DENTISTS FOR CLIENTS TO SEE