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Alex Esquire
Alex Esquire, Attorney
Category: Business Law
Satisfied Customers: 16721
Experience:  Experienced Licensed Attorney
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My son had an injury and he received emergency care (Dr.

Customer Question

My son had an injury and he received emergency care (Dr. inspected skull for Lafort fracture, cleaned gums and reinstalled evulsed teeth and stitched up beat up gums and stopped bleeding)
The Dr. did the work in his dental office and his secretary said that the insurance would not cover because work was not performed in a hospital setting and the work was done on a Sunday. Our insurance is Blue Cross Blue Shield HMO Blue without dental. The HMO people said that since it was an emergency that it should be covered after the deductible, but I forgot to mention that the work was done in a dental office. Can the insurance deny the claim even if it was an emergency and the Dr. had the requisite skills and experience to put our son back together.
Submitted: 1 year ago.
Category: Business Law
Expert:  Alex Esquire replied 1 year ago.

Hello. My name is***** will be happy to answer your question.
I am sorry to hear about this unfortunate situation.

The answer to your question would depend on the terms of your son's medical insurance coverage.

Generally, any oral surgery that is not considered dental work and results from injury is covered by the medical provider, as long as, the doctor was in network and was an oral surgeon.

I wish you the best of luck!

Customer: replied 1 year ago.

The Doctor's business card says, "Advanced Cosmetic, Implant & Reconstructive Dentistry" Does this qualify as an Oral Surgeon?

Expert:  Alex Esquire replied 1 year ago.

Thank you for your follow up.

Generally not, unless the doctor is board certified oral surgeon.

I wish you the best of luck!

Customer: replied 1 year ago.

Do we have a chance by appealing if we are denied. The injury involved jaw fractures and the Dr. was on the phone the whole time with an oral surgeon and we went to the hospital together. This was a real emergency.

Expert:  Alex Esquire replied 1 year ago.

Thank you for your follow up.

While I cannot comment on your specific case, generally emergency injuries are covered by the medical insurance, but it would depend whether the insurance company classify the services performed as emergency and not routine dental work.

If the insurance company denies to cover any of the services performed, then insured does have the right to appeal the denial.

I wish you the best of luck!

Expert:  Alex Esquire replied 1 year ago.

Please let me know if you have any related follow up questions?
If not, please positively rate and accept my answer, so I can be compensated for my work.
Thank you.

Customer: replied 1 year ago.

Initially I waited at the hospital for 50 minutes and after two coffee cups of blood I took my son away. We were fortunate to find a Dr. that could provide immediate care. My son had 3 front upper teeth knocked out, fractures to the alveolar Maxilla, basal spine fracture, four lower teeth broken off in half and a lot of blood. Will an emergency situation override the Oral Surgeon requirement and the hospital setting requirement?

Expert:  Alex Esquire replied 1 year ago.

Thank you for your follow up.

Have you been presented by the dentist with the bill?

Was this doctor within the HMO network?

Did the doctor perform any dental work, such as implants, etc,,,?

Customer: replied 1 year ago.

The Dr. secretary gave us a verbal invoice and will present us with a written one today.

The Dr. is not on the network.

The Dr. only did emergency work. (Inspect for fractures, stop bleeding, insert teeth and stitch up gums, get directions from Maxillofacial surgeon)

Expert:  Alex Esquire replied 1 year ago.

Thank you for your follow up.

Are emergency services covered by your son's insurance policy, even out of network dentists?

What is the amount of the invoice?

Customer: replied 1 year ago.

Thanks for working with me over this unending question. I got an out of network referral for the doctor for "Urgent care consultation" and I am trying to have it changed to "emergency procedure" The Member Services people tell me it is covered and the Service Provider phone people tell the Dr. that it is not covered because the treatment was not in a hospital setting. Do you think that in an appeal if we show that the service was an emergency procedure and that "in effect" the setting was a hospital that the insurance will cover?

Expert:  Alex Esquire replied 1 year ago.

Thank you for your follow up.

What is the amount of the invoice?

Customer: replied 1 year ago.

47,000

Expert:  Alex Esquire replied 1 year ago.

Thank you for your follow up.

While I cannot comment on your specific case, generally, an HMO plan would not cover an out of network medical treatment, even of an emergency nature, unless such emergency service was performed in a hospital emergency room setting.

So, while it is always possible to appeal a denial, if the appeal is denied as well, it would generally be a good idea to negotiate some type of reduction / discount for the bill with the dentist and also the dentist might offer a monthly payment plan, so the issue could be resolved.

I am very sorry to provide you with this bad news, but please understand that I do have professional obligation to provide JustAnswer.com customers with correct answers, even when answer is not favorable to the customer.

I wish you the best of luck and God bless you!

Expert:  Alex Esquire replied 1 year ago.

Please let me know if you have any related follow up questions?

If not, please positively rate and accept my answer, so I can be compensated for my work.

Thank you.

Customer: replied 1 year ago.

No coverage even if primary care Pediatrician approves a single visit out of network referral for an emergency service outside of hospital setting?

Expert:  Alex Esquire replied 1 year ago.

Thank you for your follow up.

JustAnswer.com is a pay per answer website and I have answered your original question and several follow up question in the last couple of days.

I will be happy to continue answering your new questions, once my original answer(s) is positively rated and accepted.

Thank you.