What is Patient's Financial Responsibility When Insurance Company Adjusts Claims?

My dental insurance company processed a claim by my dentist and denied it because of their contractual agreement with the provider that any fillings re-worked within 2 years are not the patient's responsibility. The provider's benefit statement regarding this service states, "The amounts shown as payable by you and by Delta Dental are in accordance with the terms of your dental plan and the terms of our agreement with your dental provider." The benefits statement shows my 80% benefit level for this service. The insurance company is not saying that I am ineligible for the benefit. Rather, they are saying that the dentist is not eligible to be paid for this service (by either the insurance company or me) based on his contract with Delta Dental and the benefits to be provided by Delta Dental and paid by the customer. The benefits statements includes notes explaining why the claim was denied. The underlying question is: "What is the patient's responsibility when the insurance provider says it is zero in accordance with the insurance agreements that all parties are abiding by?" Said differently, "Is the insurance company the final arbiter of amounts owed by the patient?" Does the insurance agreement prevail? Or does the doctor truly have the right to demand payment for amounts that the insurance company says the patient does not owe? I realize the patient is responsible for co-pays and deductibles. But I am pretty convinced that if the insurance company is denying the claim and also stating the patient has no responsibility, then the patient truly has no responsibility until and unless the provider gets the claim processed differently. The provider agreed to be bound by insurance processing when he agreed to accept this provider and its terms and benefits. Insurance companies routinely adjust the "submitted fee" downward to the "accepted/contractual" fee and providers routinely accept those adjustments (and that is one of the reasons we have this complex insurance system: to adjust charges to reasonable levels and protect patients. We pay tons of premiums for this benefit). It makes no sense to then claim the patient owes other amounts that the insurance company says the patient does not owe.
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if you have the filling done at the same office less than 2 yrs the dentist is entitle to redo it for you if it came off by accident without chargin the patient for it, but if you broke or fracture the tooth while eating then is your full responsibility to paid the full amount of the filling to the dental office because the insurance wont cover your filling less than 2 years apart from the original day to qualify again for payable benefit. therefore, when the dental office submitted the dental claim it was denied due to frequency limitation, eventhough you have a letter saying that you r not responsible for the submitted bill it best to discuss your billing question with them. because dental office most of time take x-ray for proof and patient has to sign consent form for anytype of treatment render. usually the billing the department will adjust the account if a uncorrectly billing was done during claim submission
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