Appeal rights are available to anyone covered under a dental insurance plan. If you receive an unfavorable decision on a dental claim, you can appeal the determination. Most insurers offer several levels of appeals but you must have a strong case to win. Though you have the right to appeal, in some circumstances, you will likely not win, such as trying to appeal a claim denied for a service your plan excludes. Work with your dentist to confirm valid reasons that the treatment in question is medically necessary.
Read the explanation of benefits containing the claim information you wish to dispute. Make sure you understand how the claim was paid or unpaid and the reason for the denial or why it was not paid to your satisfaction.
Call the dental insurance company to see if there is an easy way to resolve your dispute. The denial reason could be as simple as the claim did not contain enough information for the insurer to pay it. If there is a quick fix to resolving your claims issue, tell the customer service representative you will be resubmitting the claim with more information.
Write a letter stating that you wish to appeal your dental insurance claim. Gather supporting documentation such as a letter from your dentist and your dental records as well as any correspondence with the insurer. Send the letter and documents to the address listed on your denial letter or explanation of benefits. You can also file a dispute verbally by calling your insurance company and stating your intent.
Appeal your dispute to the next level if the original claim decision is upheld. Your dental insurance company will offer at least two levels of appeal using different sets of reviewers for each appeal. As with the first level appeal, you can appeal verbally or in writing.
Take your dispute to your state insurance commissioner or the Employee Benefits Security Administration if you dental plan is an ERISA plan. If you are not sure if your employer’s plan is protected under ERISA laws, ask your human resources department. Send your dispute to the Employee Benefits Security Administration, 200 Constitution Avenue, N.W., Washington, DC 20210 or visit your state’s department of insurance website for state information.
Francine Richards is a licensed multi-state insurance agent with years of human resources and insurance industry experience. Her work has appeared on Blue Cross Blue Shield websites and newsletters, the Houston Chronicle and The Nest. Richards holds a Bachelor of Arts in communications from the University of Maryland.