Dental Insurance Appeal Law – What to Do When Your Claim Gets Denied?


dental insurance appeal lawsThe dental insurance appeal law is important for anyone who is about to make a claim so they can get coverage for expenses incurred by dental care. Dental plans now offer consumers a way to receive dental care at a cost level that they can easily manage. A lot of dental plan providers have no problems promising coverage benefits to potential customers. They promise extensive coverage at low rates and several savings programs that include vision coverage, chiropractic coverage, and so on. These all sound really good, but when your time of need comes, the real test in the quality of the dental insurance plan you signed up for also comes.

Is your dental plan ready to deliver all its promised benefits? Does the company providing you with dental insurance respond promptly to your request for claims? And if your provider has denied your claim unfairly, how can you enjoy the benefits that you paid for? This is where dental insurance appeal law comes into play. Making an appeal takes a long process and you need to be familiar with the appeal laws to successfully get the claim you deserve.

What You Need to Know about the Dental Insurance Appeal Law

  • Understanding predetermination requirements
  • Requesting an appeal
  • Reviewing the appeal decision

1. Understanding predetermination requirements

Before anything else, you have to understand the predetermination requirements of dental insurance plans. Those who want to avail of the benefits of their dental insurance policy have to pass a predetermination process first to see whether their needed dental procedure is included in the set of benefits covered by their dental plan. This process should be done before the procedure begins and in conjunction with the dentist, who also wants to make sure that they will get paid for the procedure that they perform.

Although this process is not a requirement of the law, it is important to make sure that claims will be processed properly after the procedure is done. This is one way to prevent the need to make an appeal in case the claim is disapproved.

2. Requesting an appeal

If, however, your claim gets disapproved, then you need to request an appeal if you think the disapproval was unfair. Also, take note that for a claim denial to be valid, it should be communicated to the policyholder in written form, and a proper explanation should be provided in the said communication. If the policyholder, however, thinks that the claim denial is unjust, he or she must be able to file a claim within 240 days of the receipt of the denial letter. According to dental insurance appeal law, the appeal should also be made through written correspondence. If there is a need for any documents for the proper review of the claim denial, you, as the one making the claim, should also include such documents to facilitate the appeal process.

3. Reviewing the appeal decision

So what happens when you send in an appeal? Well, first, the insurance company will review the appeal carefully. The final decision should once again be sent to the policyholder through a letter. The dental insurance appeal law states that the insured should receive the final decision within 60 days from the receipt of the appeal request.

In case the insurer cannot make a decision within 60 days, the company should inform the insurer that there will be an extension in the review. However, extensions can only exceed 2 60-day periods. If the final decision is in the negative, the ERISA law states that the insurer should provide a detailed explanation of why the insured’s appeal is finally denied.

Dental Insurance Appeal Law on Additional Appeals or Civil Cases

According to dental insurance appeal law, you can still make an additional appeal even after your first appeal is denied. However, this would already entail a civil case against the insurance company providing the dental insurance plan.

Before you can file an additional appeal, however, you have to wait for a cooling off period first. This cooling off period lasts for 60 days in most states. Once the 60-day cooling off period is over, the insured can file an additional appeal and has three to five years to resolve it. This is based on the common dental insurance appeal law that governs dental claim appeals in most states.