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My wife went to a oral surgeon for a painful issue last spring and he helped her out a lot. At the time I found them on the insurance company website and thought they were in network. The doctor was, and still is, listed in their app and doesn't indicate out of network anyway. When I compare it to my primary care dentist who I know to be in network, the screen looks exactly the same.

Unfortunately, the insurance company says they are out of network on the EOB their office didn't submit the claim for several months and the claim was denied for being too late. Since they are "out of network", I have received a bill from their office for the full amount. The doctor deserved to be paid, but it's completely crazy for me to have to pay because of their screw up.

It appears to be a medical (not dental) claim and as a medical claim would have been covered in full because we had already hit the 2019 max out of pocket for her.

What's my best course? An appeal with insurance? Does them appearing in network still help any? Negotiate with the doctor for some R&C sort of charge and swallow it?
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File a complaint with your state insurance commissioner.

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Well I spoke to the insurance company first. The woman I spoke to was very sympathetic and reached out to the doctor’s office. Apparently the doctors office claimed they did file on time but IMHO that was probably only the claim for the initial consultation not the procedure. But they were going to send proof so we will see.

Another thing I found was apparently he is in network on their dental network, but not on their medical network. Of course: 1) the app doesn’t tell you that, 2) when you go to a dental provider for an issue in your mouth, how would you know it’s going to be a medical and not dental claim?

So she also said she would escalate it to get it approved as in network. Of course if it’s in network but still late, that doesn’t help much.

So she said she’d work on it and get back to me in a week.

Last recourse would be I’d like to know what the network rate for those codes are and negotiate from there instead of full price.

... we shall see...
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