May 16, 2014
Dear [redacted]:I am responding to your e-mail dated May , 2013, questioning services provided on December 27, 2013, that denied due to exceeding the maximum.We have not received federally required HIPAA authorization from the complainant to release protected health...
information concerning this account. Therefore, we can only provide a general response to this complaint.[redacted] is enrolled as the subscriber under a Fee For Service group dental plan through the State of Maryland. Her coverage is effective October 16, 2006, under Group Number [redacted].The State of Maryland had a short plan year covering July 1 to December 31, 2013. Prior to the groups open enrollment period from April 16 to April 30, 2013, the State of Maryland notified their employees that they should read the Open Enrollment materials mailed to their home or provided by their Agency Benefits Coordinator to learn how this short plan year affects their benefits. They provided their website, www.dbm.maryland.govbenefits, which states that the maximum was prorated for this short plan year. The PPO Schedule of Benefits they provided lists the maximum per member during the period of July 1 to December 31, 2013, as 750.00, excluding Class I services for diagnostic and preventative services.
These benefits were available to the subscriber or provider prior to treatment on our Automated Voice Response telephone system at ###-###-####, on our website at www.ucci.com, or by a Dental Customer Service Representative at ###-###-####. We document all telephone calls and correspondence received. There is no record that we gave incorrect benefits prior to treatment or that we stated these procedures would be paid.According to our records, we paid 750.00 for dental services provided for [redacted] from July 1, 2013 to December 31, 2013 that were not Class I services. The dental services provided on December 27, 2013 were not Class I services. Therefore, no additional payment can be made for the services provided on December 27, 2013, that denied correctly as exceeding the maximum.I have enclosed a HIPAA authorization form for you to return with the subscribers signature if you need additional information. I have also enclosed a copy of information the state provided their members concerning this maximum prior to July 1, 2013.If [redacted] has additional questions, she may call Dental Customer Service at ###-###-####.Sincerely,
December 29, 2015
I am responding to your email received December 22, 2015, concerning multiple claims for multiple patients, and the submission of necessary documentation with certain procedures.
We have not received a federally required HIPAA authorization from the patients...
involved with this complainant to release protected health information concerning these accounts. Therefore, I can only provide a general response to this complaint.On December 28, 2015, I contacted the office and spoke with [redacted] to better address the issue concerning the denials of claims and the necessary documentation that should be included with the claims. I informed her how to locate the information via the provider portal in our website, information in our Dental Reference Guide regarding our policies, diagnostic material requirements, claims address, and submissions for appeals and second reviews. I am currently working with [redacted] to help her with a claim for a specific member and left communication open between us, in case she may have any additional questions regarding submissions, reviews, policies, etc.
If you have any additional questions, feel free to contact me.
Sincerely,
Serena W.
Specialized Services Unit Representative
October 16, 2014Dear [redacted]:I am writing in response to your letter dated October 14, 2014, concerning [redacted]. We received this letter on October 14, 2014.[redacted] indicates she should not have been sent to collections regarding her premium payments. As...
indicated in our letter dated October 10, 2014, the checks [redacted] sent were not able to be identified initially. Thus, while research was taking place, her account lapsed and was sent to collections. This has been cleared up and our records reflect that any reference to collections has been cancelled. Though we cannot speak for the collections office, it may take additional time for their records to catch up and reflect this same information.If we may be of further assistance, please feel free to contact Dental Customer Service at: ###-###-####.Sincerely,Lisa R
Specialized Services Representative
Good Afternoon [redacted]
United Concordia received complaint ID [redacted] from your department on 7/28/2014. Based on the information provided we are unable to identify the subscriber and address their concerns. We tried calling the member at the phone number...
referenced on the complaint but was unable to contact the subscriber. We would need a valid United Concordia identification number to address the concerns in this complaint.
January 15, 2016
Dear [redacted]:
I am responding to your email dated January 8, 2016, concerning a complaint you received from [redacted], and the participation and/or non-participation of a dental office. We received your email on January 8, 2016.
We have not received...
a federally required HIPAA authorization from the complainant to release protected health information concerning this account.Sincerely,Deb R.
Specialized Services Representative
I am responding to your email, which we received on April 22, 2016, concerning a denied claim for dental services provided for the subscriber's wife on February 1, 2016.
Due to the Federal Health Insurance Portability and Accountability Act (HIPAA Privacy Act), we are unable to provide...
protected health information without the patient's written consent. have enclosed a copy of our Request and Authorization for Disclosure of Health Information form. Please resubmit your request with this completed form if you need detailed information. Please contact me if you have any additional questions.
Sincerely,Marta M[redacted], Sr. Service RepresentativeDental Customer Service Specialized Service UnitEnclosure
[A default letter is provided here which indicates your acceptance of the business's response. If you wish, you may update it before sending it.]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. Although, I did not receive the check sent out on May 30th as they report. Are we able to look further into this? They can research into their accounting records that it was never cashed. Is it able to be resent or credited directly to my bank account?
Regards,
[redacted]
September 3, 2015
Dear [redacted]:I am responding to your email received on August 25, 2015, concerning a complaint you received from [redacted], regarding his dissatisfaction with processing his claim by non-participating provider [redacted]. We received this email on...
August 25, 2015.We have not received federally required HIPAA authorization from the complainant to release protected health information concerning this account. Therefore, we can only provide a general response to the information you provided in this complaint.
The claim was received without the required diagnostic materials. A payment was issued to the provider on August 27, 2015, for the services that did not require review or diagnostic materials. I spoke with the provider’s office on September 02, 2015, and they have agreed to send the required diagnostic materials. Once received, I will send the claim and the attachments for processing.A detailed explanation was sent to the Commonwealth of Virginia replying to a complaint they received from [redacted] regarding the same issue.
I have enclosed a HIPAA authorization form for you to return with the subscriber’s signature if you need additional information. If you have any questions concerning this form, please call our Privacy Department at ###-###-####. If [redacted] has additional questions, he may call Dental Customer Service at ###-###-####.
Sincerely,
Deb R.
Specialized Services Representative
[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]
Complaint: [redacted]
I am rejecting this response because:
My credit is still under threat. I will be satisfied to close this complaint when I receive written confirmation from the collections agency indicating I am not longer being pursued for this money. Please submit this to me. Thank you.
Regards,
[redacted]
May 14, 2014
[redacted]:I am writing in response to a complaint submitted on May 4, 2014 by [redacted] regarding the denial for a prefabricated post and core on Tooth Number 20 provided on date of service December 10, 2013. We received your email on May 5, 2014.**. [redacted]...
is covered as the member under the [redacted]) effective January 1, 2011, under Group Number [redacted]. This program is offered by the U.S. Office of Personnel Management (OPM). United Concordia administers and underwrites [redacted] for OPM. As a Federal plan, [redacted] is not subject to state insurance laws. As a courtesy, I am providing you with the following information.All claims are processed according to the terms of the subscriber’s contract and the information reported on the claim form. United Concordia Dental contracts include provisions requiring input from our Dentist Advisors to determine financial responsibility. We are responsible for ensuring that payment is appropriate for the care our subscribers receive. Our dental review program fulfills this responsibility.United Concordia Dentist Advisors review cases by studying claims history, reports, correspondence and diagnostic information such as radiographs. Following the review the claim is processed based on the Advisor’s opinion and the subscriber’s contract.On January 27, 2014, we received claim number [redacted] for date of service December 10, 2013, for a prefabricated post and core on Tooth Number 20. The Dental Claims Department recognized that this non-participating provider ([redacted], DMD) submitted services on an unacceptable dental claim form and sent a letter to Dr. [redacted] explaining how to obtain an acceptable claim form. A copy of this letter is enclosed for your reference.The provider community was informed of updates to the claim form on the American Dental Association website (www.ada.org), United Concordia’s website (www.ucci.com1), the ADANews. and United Concordia’s newsletter the Connection.On March 17, 2014, we received claim number [redacted] for a prefabricated post and core on Tooth Number 20. On March 24, 2014, a letter was sent to Dr. [redacted] requesting a pretreatment radiograph of Tooth Number 20 (prior to crown preparation/insertion) of the completed root canal showing the entire apices. The claim denied because we did not receive the requested information within the allotted timeframe. A copy of this letter is enclosed for your reference.On March 26, 2014, **. [redacted] called United Concordia questioning the status of his claim for date of service December 10, 2013, and was advised we needed an X-ray showing the apices.I spoke to [redacted] and Dr. [redacted] on May 14, 2014, and explained what was required for a second review and where to send the information.If I may be of further assistance, please contact me.
September 29, 2014Dear [redacted]:I am responding to your letter regarding coverage for [redacted] and [redacted]. Your letter was received on September 22, 2014.**. and [redacted] are covered on a dental PPO planthrough [redacted]. The effective date of coverage...
was May 1, 2014, undergroup number [redacted].The iDental plans through United Concordia will no longer be available as of January 1, 2015. The members were sent a letter advising them of another plan in place that they can enroll in where the waiting periods would be waived. For more information on this plan the member can contact the sales department at [redacted].
I hope this information will be helpful. Please feel free to contact me if you have any questions.Sincerely,Nyla J
Specialized Services Representative
April 20, 2015Dear [redacted]:I am responding to your email received on April 15, 2015, requesting payment in full for dental services provided on December 4, 2014, and January 21, 2015, by [redacted] of Pottstown, Pennsylvania. We have now paid both of these services dates as an exception to the contract.I sent the HIPAA authorization from included with this request to our Privacy Department for review. They will notify the subscriber of their decision when their review is completed.When I previously spoke to [redacted] on March 9, 2015, I told her these claims would be paid in accordance with the dental contract, as they have. I did not state they would be paid in full. In fact, I told her the contract requires her to pay co-pays for the procedures provided. This is when she decided not to change her PDO because she said her current PDO does not bill her copays as they can. We c[redacted]ot discriminate against other group members with the same co-pays by paying claims differently for [redacted].I sent [redacted] a copy of her dental benefits and co-pay schedule which lists her liability for the procedures performed.Sincerely,
Marta M
Sr. Service Representative Dental Customer Service Specialized Service Unit
[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]
Complaint: [redacted]
I am rejecting this response because: We are aware of everything stated in this letter. In fact, all it says that we began with United Concordia in May 2014 and will no longer be enrolled as of Jan 2015.
THE ISSUE WE HAVE IS THAT THERE IS A 12 MONTH WAITING PERIOD BEFORE WE ARE ABLE TO USE THIS INSURANCE. SO WE HAVE PAID FOR THIS INSURANCE SINCE MAY 2014 BUT WE WILL NEVER GET TO USE THIS INSURANCE BECUASE WE WILL NO LONGER BE ENROLLED AS OF JAN 2015.
We would like a refund of our money because we never even got past our waiting period.
As stated in previous email (see below) - we would like a refund;
We would like our money back.
We each have paid - Year to date $311.67.
We have 2 separate policies:
[redacted] - Member ID#[redacted] - Plan/Group# [redacted]
[redacted] - Member ID#[redacted] - Plan/Group #[redacted]
Regards,
[redacted]
April 24, 2014
Dear **. [redacted]:I am writing in response to your letter dated April 21, 2014, concerning [redacted]’s questions about our response dated April 18, 2014. We received this letter on April 21, 2014.**. [redacted] questioned our “Dentist Advisor” making decisions on patient treatment. United Concordia would never propose that patients deny themselves necessary care. In all situations, a provider must use their professional judgment to provide care they believe to be in the best interest of the patient. As always, the dentist and member are responsible for treatment decisions. Our determinations are made for coverage purposes only and cannot supersede the professional judgment of the treating dentist.**. [redacted] states that United Concordia expects an exceptional amount of documentation with regard to periodontal scaling and root planing services. All claims are processed according to the terms of the subscriber’s contract and the information reported on the claim form. United Concordia Dental contracts include provisions requiring input from our Dentist Advisors to determine United Concordia’s financial responsibility. We are responsible for ensuring that payment is appropriate for the care our subscribers receive. Our dental review program fulfills this responsibility.United Concordia Dentist Advisors review cases by studying claims history, reports, correspondence and diagnostic information such as radiographs. Following the review, the claim is processed based on the Advisor’s opinion and the subscriber’s contract.In addition, **. [redacted] questions our policy with regard to periapical radiographs. Periapical radiographs performed on the same date as a periodic oral evaluation requires review by a Dentist Advisor. This policy was put in place in part to prevent routine taking of radiographs, unless a specific reason is documented and in keeping with the American Dental Associations recommendation on taking of periapical radiographs without a specific diagnostic reason.
**. [redacted] believes that United Concordia did not respond to multiple requests for a dental predetermination submitted by Dr. [redacted]. As was indicated during conversations with **. [redacted], we have never received a predetermination request for any services to be provided by Dr. [redacted]. We did receive a claim for services dated February 18, 2014, for [redacted]. However, prior to those services actually being done on that date, we did not receive any request for a predetermination for services to be provided by Dr. [redacted].If I may be of further assistance, please feel free to contact me directly.
Sincerely,
May 16, 2014
Dear [redacted]:I am responding to your e-mail dated May , 2013, questioning services provided on December 27, 2013, that denied due to exceeding the maximum.We have not received federally required HIPAA authorization from the complainant to release protected health...
information concerning this account. Therefore, we can only provide a general response to this complaint.[redacted] is enrolled as the subscriber under a Fee For Service group dental plan through the State of Maryland. Her coverage is effective October 16, 2006, under Group Number [redacted].The State of Maryland had a short plan year covering July 1 to December 31, 2013. Prior to the groups open enrollment period from April 16 to April 30, 2013, the State of Maryland notified their employees that they should read the Open Enrollment materials mailed to their home or provided by their Agency Benefits Coordinator to learn how this short plan year affects their benefits. They provided their website, www.dbm.maryland.govbenefits, which states that the maximum was prorated for this short plan year. The PPO Schedule of Benefits they provided lists the maximum per member during the period of July 1 to December 31, 2013, as 750.00, excluding Class I services for diagnostic and preventative services.
These benefits were available to the subscriber or provider prior to treatment on our Automated Voice Response telephone system at ###-###-####, on our website at www.ucci.com, or by a Dental Customer Service Representative at ###-###-####. We document all telephone calls and correspondence received. There is no record that we gave incorrect benefits prior to treatment or that we stated these procedures would be paid.According to our records, we paid 750.00 for dental services provided for [redacted] from July 1, 2013 to December 31, 2013 that were not Class I services. The dental services provided on December 27, 2013 were not Class I services. Therefore, no additional payment can be made for the services provided on December 27, 2013, that denied correctly as exceeding the maximum.I have enclosed a HIPAA authorization form for you to return with the subscribers signature if you need additional information. I have also enclosed a copy of information the state provided their members concerning this maximum prior to July 1, 2013.If [redacted] has additional questions, she may call Dental Customer Service at ###-###-####.Sincerely,
December 29, 2015
I am responding to your email received December 22, 2015, concerning multiple claims for multiple patients, and the submission of necessary documentation with certain procedures.
We have not received a federally required HIPAA authorization from the patients...
involved with this complainant to release protected health information concerning these accounts. Therefore, I can only provide a general response to this complaint.On December 28, 2015, I contacted the office and spoke with [redacted] to better address the issue concerning the denials of claims and the necessary documentation that should be included with the claims. I informed her how to locate the information via the provider portal in our website, information in our Dental Reference Guide regarding our policies, diagnostic material requirements, claims address, and submissions for appeals and second reviews. I am currently working with [redacted] to help her with a claim for a specific member and left communication open between us, in case she may have any additional questions regarding submissions, reviews, policies, etc.
If you have any additional questions, feel free to contact me.
Sincerely,
Serena W.
Specialized Services Unit Representative
October 16, 2014Dear [redacted]:I am writing in response to your letter dated October 14, 2014, concerning [redacted]. We received this letter on October 14, 2014.[redacted] indicates she should not have been sent to collections regarding her premium payments. As...
indicated in our letter dated October 10, 2014, the checks [redacted] sent were not able to be identified initially. Thus, while research was taking place, her account lapsed and was sent to collections. This has been cleared up and our records reflect that any reference to collections has been cancelled. Though we cannot speak for the collections office, it may take additional time for their records to catch up and reflect this same information.If we may be of further assistance, please feel free to contact Dental Customer Service at: ###-###-####.Sincerely,Lisa R
Specialized Services Representative
Good Afternoon [redacted]
United Concordia received complaint ID [redacted] from your department on 7/28/2014. Based on the information provided we are unable to identify the subscriber and address their concerns. We tried calling the member at the phone number...
referenced on the complaint but was unable to contact the subscriber. We would need a valid United Concordia identification number to address the concerns in this complaint.
Thank you,
Amy *. R[redacted]
January 15, 2016
Dear [redacted]:
I am responding to your email dated January 8, 2016, concerning a complaint you received from [redacted], and the participation and/or non-participation of a dental office. We received your email on January 8, 2016.
We have not received...
a federally required HIPAA authorization from the complainant to release protected health information concerning this account.Sincerely,Deb R.
Specialized Services Representative
I am responding to your email, which we received on April 22, 2016, concerning a denied claim for dental services provided for the subscriber's wife on February 1, 2016.
Due to the Federal Health Insurance Portability and Accountability Act (HIPAA Privacy Act), we are unable to provide...
protected health information without the patient's written consent. have enclosed a copy of our Request and Authorization for Disclosure of Health Information form. Please resubmit your request with this completed form if you need detailed information. Please contact me if you have any additional questions.
Sincerely,Marta M[redacted], Sr. Service RepresentativeDental Customer Service Specialized Service UnitEnclosure
[A default letter is provided here which indicates your acceptance of the business's response. If you wish, you may update it before sending it.]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. Although, I did not receive the check sent out on May 30th as they report. Are we able to look further into this? They can research into their accounting records that it was never cashed. Is it able to be resent or credited directly to my bank account?
Regards,
[redacted]
September 3, 2015
Dear [redacted]:I am responding to your email received on August 25, 2015, concerning a complaint you received from [redacted], regarding his dissatisfaction with processing his claim by non-participating provider [redacted]. We received this email on...
August 25, 2015.We have not received federally required HIPAA authorization from the complainant to release protected health information concerning this account. Therefore, we can only provide a general response to the information you provided in this complaint.
The claim was received without the required diagnostic materials. A payment was issued to the provider on August 27, 2015, for the services that did not require review or diagnostic materials. I spoke with the provider’s office on September 02, 2015, and they have agreed to send the required diagnostic materials. Once received, I will send the claim and the attachments for processing.A detailed explanation was sent to the Commonwealth of Virginia replying to a complaint they received from [redacted] regarding the same issue.
I have enclosed a HIPAA authorization form for you to return with the subscriber’s signature if you need additional information. If you have any questions concerning this form, please call our Privacy Department at ###-###-####. If [redacted] has additional questions, he may call Dental Customer Service at ###-###-####.
Sincerely,
Deb R.
Specialized Services Representative
[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]
Complaint: [redacted]
I am rejecting this response because:
My credit is still under threat. I will be satisfied to close this complaint when I receive written confirmation from the collections agency indicating I am not longer being pursued for this money. Please submit this to me. Thank you.
Regards,
[redacted]
May 14, 2014
[redacted]:I am writing in response to a complaint submitted on May 4, 2014 by [redacted] regarding the denial for a prefabricated post and core on Tooth Number 20 provided on date of service December 10, 2013. We received your email on May 5, 2014.**. [redacted]...
is covered as the member under the [redacted]) effective January 1, 2011, under Group Number [redacted]. This program is offered by the U.S. Office of Personnel Management (OPM). United Concordia administers and underwrites [redacted] for OPM. As a Federal plan, [redacted] is not subject to state insurance laws. As a courtesy, I am providing you with the following information.All claims are processed according to the terms of the subscriber’s contract and the information reported on the claim form. United Concordia Dental contracts include provisions requiring input from our Dentist Advisors to determine financial responsibility. We are responsible for ensuring that payment is appropriate for the care our subscribers receive. Our dental review program fulfills this responsibility.United Concordia Dentist Advisors review cases by studying claims history, reports, correspondence and diagnostic information such as radiographs. Following the review the claim is processed based on the Advisor’s opinion and the subscriber’s contract.On January 27, 2014, we received claim number [redacted] for date of service December 10, 2013, for a prefabricated post and core on Tooth Number 20. The Dental Claims Department recognized that this non-participating provider ([redacted], DMD) submitted services on an unacceptable dental claim form and sent a letter to Dr. [redacted] explaining how to obtain an acceptable claim form. A copy of this letter is enclosed for your reference.The provider community was informed of updates to the claim form on the American Dental Association website (www.ada.org), United Concordia’s website (www.ucci.com1), the ADANews. and United Concordia’s newsletter the Connection.On March 17, 2014, we received claim number [redacted] for a prefabricated post and core on Tooth Number 20. On March 24, 2014, a letter was sent to Dr. [redacted] requesting a pretreatment radiograph of Tooth Number 20 (prior to crown preparation/insertion) of the completed root canal showing the entire apices. The claim denied because we did not receive the requested information within the allotted timeframe. A copy of this letter is enclosed for your reference.On March 26, 2014, **. [redacted] called United Concordia questioning the status of his claim for date of service December 10, 2013, and was advised we needed an X-ray showing the apices.I spoke to [redacted] and Dr. [redacted] on May 14, 2014, and explained what was required for a second review and where to send the information.If I may be of further assistance, please contact me.
September 29, 2014Dear [redacted]:I am responding to your letter regarding coverage for [redacted] and [redacted]. Your letter was received on September 22, 2014.**. and [redacted] are covered on a dental PPO planthrough [redacted]. The effective date of coverage...
was May 1, 2014, undergroup number [redacted].The iDental plans through United Concordia will no longer be available as of January 1, 2015. The members were sent a letter advising them of another plan in place that they can enroll in where the waiting periods would be waived. For more information on this plan the member can contact the sales department at [redacted].
I hope this information will be helpful. Please feel free to contact me if you have any questions.Sincerely,Nyla J
Specialized Services Representative
April 20, 2015Dear [redacted]:I am responding to your email received on April 15, 2015, requesting payment in full for dental services provided on December 4, 2014, and January 21, 2015, by [redacted] of Pottstown, Pennsylvania. We have now paid both of these services dates as an exception to the contract.I sent the HIPAA authorization from included with this request to our Privacy Department for review. They will notify the subscriber of their decision when their review is completed.When I previously spoke to [redacted] on March 9, 2015, I told her these claims would be paid in accordance with the dental contract, as they have. I did not state they would be paid in full. In fact, I told her the contract requires her to pay co-pays for the procedures provided. This is when she decided not to change her PDO because she said her current PDO does not bill her copays as they can. We c[redacted]ot discriminate against other group members with the same co-pays by paying claims differently for [redacted].I sent [redacted] a copy of her dental benefits and co-pay schedule which lists her liability for the procedures performed.Sincerely,
Marta M
Sr. Service Representative Dental Customer Service Specialized Service Unit
[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]
Complaint: [redacted]
I am rejecting this response because: We are aware of everything stated in this letter. In fact, all it says that we began with United Concordia in May 2014 and will no longer be enrolled as of Jan 2015.
THE ISSUE WE HAVE IS THAT THERE IS A 12 MONTH WAITING PERIOD BEFORE WE ARE ABLE TO USE THIS INSURANCE. SO WE HAVE PAID FOR THIS INSURANCE SINCE MAY 2014 BUT WE WILL NEVER GET TO USE THIS INSURANCE BECUASE WE WILL NO LONGER BE ENROLLED AS OF JAN 2015.
We would like a refund of our money because we never even got past our waiting period.
As stated in previous email (see below) - we would like a refund;
We would like our money back.
We each have paid - Year to date $311.67.
We have 2 separate policies:
[redacted] - Member ID#[redacted] - Plan/Group# [redacted]
[redacted] - Member ID#[redacted] - Plan/Group #[redacted]
Regards,
[redacted]
April 24, 2014
Dear **. [redacted]:I am writing in response to your letter dated April 21, 2014, concerning [redacted]’s questions about our response dated April 18, 2014. We received this letter on April 21, 2014.**. [redacted] questioned our “Dentist Advisor” making decisions on patient treatment. United Concordia would never propose that patients deny themselves necessary care. In all situations, a provider must use their professional judgment to provide care they believe to be in the best interest of the patient. As always, the dentist and member are responsible for treatment decisions. Our determinations are made for coverage purposes only and cannot supersede the professional judgment of the treating dentist.**. [redacted] states that United Concordia expects an exceptional amount of documentation with regard to periodontal scaling and root planing services. All claims are processed according to the terms of the subscriber’s contract and the information reported on the claim form. United Concordia Dental contracts include provisions requiring input from our Dentist Advisors to determine United Concordia’s financial responsibility. We are responsible for ensuring that payment is appropriate for the care our subscribers receive. Our dental review program fulfills this responsibility.United Concordia Dentist Advisors review cases by studying claims history, reports, correspondence and diagnostic information such as radiographs. Following the review, the claim is processed based on the Advisor’s opinion and the subscriber’s contract.In addition, **. [redacted] questions our policy with regard to periapical radiographs. Periapical radiographs performed on the same date as a periodic oral evaluation requires review by a Dentist Advisor. This policy was put in place in part to prevent routine taking of radiographs, unless a specific reason is documented and in keeping with the American Dental Associations recommendation on taking of periapical radiographs without a specific diagnostic reason.
**. [redacted] believes that United Concordia did not respond to multiple requests for a dental predetermination submitted by Dr. [redacted]. As was indicated during conversations with **. [redacted], we have never received a predetermination request for any services to be provided by Dr. [redacted]. We did receive a claim for services dated February 18, 2014, for [redacted]. However, prior to those services actually being done on that date, we did not receive any request for a predetermination for services to be provided by Dr. [redacted].If I may be of further assistance, please feel free to contact me directly.
Sincerely,