Make it Simple for Someone else Today: Take out your last explanation of benefits from your insurance company. Read the entire form. Explain the form to one other person, a parent, a child, a friend. Highlight information you didn't know about that caught your attention.
I picked up a dental explanation of benefits for PREVENTIVE CARE. Preventive care is usually best covered by insurance companies because it represents FINITE costs, in other words, it requires nothing in terms of "insuring" because it is not covering the RISK OF PAYING FOR NEEDED DENTAL SERVICES but is instead covering the cost of a checkup.
Note the date of service. Because insurance companies and medical services providers do not use the same number for invoices or reference numbers or claims numbers, the date of service is the easiest way to track your care. Use the date of service on all correspondence and payments for services.
The charges came to $154.00. Coverage is described at 80% excluding $24 for fluoride. The insurance company therefore uses $125.00 as the submitted expense ($154 less UNCOVERED $24) and will cover 80% of that bill, $100. Patient's financial responsibility is $54 but this amount is only $25 out of pocket because insurance companies don't include amounts they don't cover at all. The dentist has received $100.00.
We are advised that we can search a specific website for specific dentists who are part of the plan.
Things to share: Date of service, how out of pocket expenses are calculated, uncovered parts of preventive care (in this case the fluoride treatment). Annual Maximum, the limit on how much the insurer will pay. This number is the same as the famed DOUGHNUT HOLE of Medicare Prescription plans, it names the maximum amount the insurer will pay out. In our case, the $100 paid for preventive care is deducted from a maximum amount of $2000 that will be covered by our insurer.
The reverse part of the form describes how we can appeal and "adverse benefit determination" which is done in writing and is done by writing a letter to the address listed.
If you're not bored yet, you can write a mock appeal letter:
Address for appeals
Your address
Reference line including your name, your plan number, your insurance statement reference number and date of service
Appeals:
This is our notice of appeal for the above referenced denial of benefits.
Then name your issue, for instance, our preventive care includes fluoride treatments which you excluded from coverage. It is usual and customary for preventive treatment to include fluoride treatments. (Any supporting evidence? include it here).
Sign your name
Thank the person for listening to you explain the explanation of benefits form to him/her. Ask them if there are any questions or if there's anything that surprised them about the form.
You have just performed an educational good deed for yourself and someone else, Happy New Year!
