Decode a scary dental insurance denial and confirm the real bill with Claude Code
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Here is an Explanation of Benefits from my dental insurance and my policy documents. Six of eight lines say denied and my share looks like $1,316. Explain what is going on and what I actually owe.
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Before you start, ask me 1–3 short questions about the details below and wait for my answers. Once I've answered, confirm the plan in one line and run the whole task start to finish. Goal: Work out what an insurance Explanation of Benefits (EOB) really means and what I actually owe. Questions to ask me first: - Which insurer and plan is this, and is the provider in network? - Has the provider already quoted you a price or set up a payment plan? - Do you have the full policy or benefits booklet? Inputs (fill in or confirm): - The EOB (photo or PDF): [EOB] - Policy or benefits booklet: [POLICY DOCUMENTS] - Provider's quote or bill: [PROVIDER BILL] - What I've already paid: [PAYMENTS SO FAR] Rules: - Go line by line: service, amount billed, allowed amount, what insurance paid and my share. - Quote the policy section behind every denial or exclusion. - Explain in-network contracted rates and whether the provider can bill me more than the allowed amount. - Don't tell me something is an error unless the documents show it; list anything uncertain as a question for the insurer. Checkpoint: Show me the line-by-line table first and wait for me to confirm it matches the EOB before you give the bottom line. If you get stuck: If a code or term isn't explained in my documents, say so and give me the exact question to ask the insurer. Verify before you finish: Check that the totals in your table add up to the totals on the EOB. Output: A plain-English summary, the line-by-line table, what I owe and a short script for calling the insurer or provider if anything is wrong. Done when: I know what I actually owe and whether anything needs to be disputed.
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Outcome
John Sambrook, 66, woke at 4:30 a.m. to an Aetna Explanation of Benefits for some dental fillings: six of the eight line items said DENIED, and the 'Your Share' column added up to $1,316. Sambrook had spent about 15 minutes setting up a small Claude Code workspace for personal insurance, with the policy documents in it, and asked it to explain the EOB. About three minutes later, it showed that the plan excludes 'comprehensive dental services', so the denials were expected, but that the dentist is in network and bills at a contracted rate. The actual amount owed was $723.83, the figure already being paid, so nothing more was due.
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Source
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- by John Sambrook (Common Sense Systems)
- Last checked
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https://common-sense.com/insights/insurance-denial-resolved-before-coffee/
Context: Sambrook runs a consulting firm and offers paid help setting up this kind of workspace on the same page.
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