QCS

Delta Dental Plan of Michigan, Inc("DDMI"), (NAIC #54305), is in receipt of your letter datedJuly 17,2015, directed to Delta Dental Plan of Ohio, Inc("DDOH")DDMI is the claimsadministrator to DDOH (NAIC # 54402)Upon receipt, our Customer Service department promptlyresearched your
inquiry.*** *** receives dental benefit coverage as a dependent under a dental program sponsoredby *** ***'s employer, *** *** *** (the "Group")This plan is a self-fundeddental benefit plan sponsored by the Group and is governed by the Employee Retirement IncomeSecurity Act of ("ERISA")The Group determines the level of benefits provided to itssubscribers and their eligible dependents ("Plan").The Group plan allows oral examinations or evaluations twice per benefit year, regardless of theDentist's specialty (see page of the Group's Plan, attached)*** *** had examinationscompleted on 6/18/2015, 6/22/and 6/24/by three different providers (see attachedexplanation of benefits)Therefore, the claim for date of service 6/24/was properly processedaccording to the Group's Plan.We believe this letter adequately addresses your concernsIf you have any further questions, pleasecontact me at *** or ###-###-####Sincerely, ***

Delta Dental of Michigan ("DDMI") (NAIC #***) is in receipt of your letter regarding Revdex.com ComplaintID ***Upon receipt, our Customer Service department promptly researched your inquiry.On January 15, 2016, Ms*** purchased an EHB-certified policy through the Health Care
Marketplace("Marketplace"), the Marketplace directed her to enroll through Delta Dental's website:www.mysmilecoverage.com ("Enrollment Website")In her complaint, Ms*** states that upon herenrollment, she was not provided information on Delta Dental's website regarding the difference betweena PPO Dentist and a Premier Dentist (Nonparticipating Dentist)Subsequent to Ms*** enrolling in herdental plan she attended a routine dental appointment at her provider's office on February 2, 2016.Initially upon choosing to sign up for a plan via the Enrollment Website, there are two options provided, ahigh and low planOn this page you can calculate your rate for the area you live inYou also have theoption to view a Benefits Page that is linked in the plan description (see attached screenshot #1)If youopt to review the Benefits Page before enrolling in the plan you are able to review the coverage amountsfor both PPO and Premier Dentists, non-participating (see attached screenshot #2)Before signing upwith a DDMI plan there is an option to review the Benefits Page which sets forth the specific coverageinformation that Ms*** would have needed to determine coverage with a Premier Provider.Furthermore, on February 2, 2016, the day Ms*** was at the dentist office, our Customer ServiceDepartment received a call from the provider's oficeThe provider used DDMI's automated systemrequesting a fax of the subscriber's benefitsThe document requested by the provider's office onFebruary 2, 2016, also set forth the percentages of coverage for a PPO or Premier Provider, nonparticipating.Pursuant to the foregoing information, DDMI stands by its determinationUnder the plan purchased byMs*** a Premier Provider is covered at 80% according to the terms of the contract.We believe this correspondence adequately addresses Ms***' concernsIf you have any furtherquestions, please contact me by telephone at ###-###-#### or by email [email protected]

Delta Dental Plan of Michigan, Inc(“DDPMI”) (NAIC # 54305) is in receipt of your letterdirected to Delta Dental Plan of Ohio, Inc(“DDOH”), NAIC #DDOH is the underwriterand DDMI is the claims administrator.*** *** receives dental benefits under a fully-insured *** dental
program sponsored byher employer, *** *** (the “***”)The *** determines the level of dental benefits thatare available to its subscribers and their dependents.In her inquiry, Ms*** asserts that DDMI improperly denied a pretreatment estimate for acrown on tooth #Careful review of DDMI’s records determined that the pretreatment estimatewas properly denied pursuant to the ***’s PlanTherefore, the denial will stand.DDMI’s records reflect that Ms*** received an onlay on tooth #on 3/5/The onlaywas placed by a participating provider’s office, *** *** *** ***., and benefitcoverage was provided and paid to the providerSee attached Explanation of BenefitsMs.*** claims that the onlay failed within the first year and that she required a crownWhen asubscriber is unhappy with the quality of treatment performed by a participating provider, theymay submit a letter to DDMI requesting that a quality of care case be initiatedPursuant to theprovider’s participation agreement, DDMI would then work with the provider and the subscriberto determine if the provider is able to perform additional treatment in order to satisfy thesubscriber and/or take necessary corrective action to perform treatment that meets generallyacceptable dental standardsHowever, a quality of care case was not initiated by Ms*** inthis matter.According to the level of benefits selected by the ***, restorative services such as onlays andcrowns are payable only once in a five-year periodSee attached excerpt from the ***’sCertificateThis five-year limitation period applies to future restorative services provided on thesame tooth within that five-year periodThis is a contractual limitation determined by the ***,not a DDMI policyDDMI may not override the terms of the ***’s contractTherefore,DDMI’s determination to deny the second restorative treatment (crown) on tooth #was correctand will stand.We believe this correspondence adequately addresses Ms***’s concernsIf you have anyfurther questions, please contact me by telephone at ###-###-#### or by email at ***Sincerely,***

Delta Dental of Michigan ("DDMI") (NAIC #***) is in receipt of your letter regarding Revdex.com ComplaintID ***Upon receipt, our Customer Service department promptly researched your inquiry.On January 15, 2016, Ms*** purchased an EHB-certified policy through the Health Care
Marketplace("Marketplace"), the Marketplace directed her to enroll through Delta Dental's website:www.mysmilecoverage.com ("Enrollment Website")In her complaint, Ms*** states that upon herenrollment, she was not provided information on Delta Dental's website regarding the difference betweena PPO Dentist and a Premier Dentist (Nonparticipating Dentist)Subsequent to Ms*** enrolling in herdental plan she attended a routine dental appointment at her provider's office on February 2, 2016.Initially upon choosing to sign up for a plan via the Enrollment Website, there are two options provided, ahigh and low planOn this page you can calculate your rate for the area you live inYou also have theoption to view a Benefits Page that is linked in the plan description (see attached screenshot #1)If youopt to review the Benefits Page before enrolling in the plan you are able to review the coverage amountsfor both PPO and Premier Dentists, non-participating (see attached screenshot #2)Before signing upwith a DDMI plan there is an option to review the Benefits Page which sets forth the specific coverageinformation that Ms*** would have needed to determine coverage with a Premier Provider.Furthermore, on February 2, 2016, the day Ms*** was at the dentist office, our Customer ServiceDepartment received a call from the provider's oficeThe provider used DDMI's automated systemrequesting a fax of the subscriber's benefitsThe document requested by the provider's office onFebruary 2, 2016, also set forth the percentages of coverage for a PPO or Premier Provider, nonparticipating.Pursuant to the foregoing information, DDMI stands by its determinationUnder the plan purchased byMs*** a Premier Provider is covered at 80% according to the terms of the contract.We believe this correspondence adequately addresses Ms***' concernsIf you have any furtherquestions, please contact me by telephone at ###-###-#### or by email [email protected]

? Delta Dental Plan of Michigan, Inc(“DDPMI”) (NAIC # 54305) is in receipt of your letterdirected to Delta Dental Plan of Ohio, Inc(“DDOH”), NAIC #DDOH is the underwriterand DDMI is the claims administrator.*** *** receives dental benefits under a fully-insured *** dental
program sponsored byher employer, *** *** (the “***”)The *** determines the level of dental benefits thatare available to its subscribers and their dependents.In her inquiry, Ms*** asserts that DDMI improperly denied a pretreatment estimate for acrown on tooth #Careful review of DDMI’s records determined that the pretreatment estimatewas properly denied pursuant to the ***’s PlanTherefore, the denial will stand.DDMI’s records reflect that Ms*** received an onlay on tooth #on 3/5/The onlaywas placed by a participating provider’s office, *** *** *** ***., and benefitcoverage was provided and paid to the providerSee attached Explanation of BenefitsMs.*** claims that the onlay failed within the first year and that she required a crownWhen asubscriber is unhappy with the quality of treatment performed by a participating provider, theymay submit a letter to DDMI requesting that a quality of care case be initiatedPursuant to theprovider’s participation agreement, DDMI would then work with the provider and the subscriberto determine if the provider is able to perform additional treatment in order to satisfy thesubscriber and/or take necessary corrective action to perform treatment that meets generallyacceptable dental standardsHowever, a quality of care case was not initiated by Ms*** inthis matter.According to the level of benefits selected by the ***, restorative services such as onlays andcrowns are payable only once in a five-year periodSee attached excerpt from the ***’sCertificateThis five-year limitation period applies to future restorative services provided on thesame tooth within that five-year periodThis is a contractual limitation determined by the ***,not a DDMI policyDDMI may not override the terms of the ***’s contractTherefore,DDMI’s determination to deny the second restorative treatment (crown) on tooth #was correctand will stand.We believe this correspondence adequately addresses Ms***’s concernsIf you have anyfurther questions, please contact me by telephone at ###-###-#### or by email at ***Sincerely,***?

I called delta dental to complain about a dentist that I thought was overcharging patients and the insurance and Delta Dental is the one that said get another opinion. I followed their instructions and now they act like they don't care or didn't say that. I called them to report a potential bad dentist and now because I did what they told me they won't pay for my exam?? Does that make sense to you? We live in a country where instead of a company fixing the problem and doing the right thing they do everything they can not to pay a claim or help a patient. This is wrong and sad. 
Regards,
[redacted]