How to Appeal a Dental Insurance Claim Denial

Receiving a denial letter from your dental insurance company can be frustrating, especially when you believed a procedure would be covered. But a denial does not have to be the final answer. You have the right to appeal the decision, and many denied claims are overturned when patients take the time to go through the appeals process.

Industry estimates suggest that approximately 10% to 20% of dental claims are initially denied. Many of those denials are due to fixable issues like billing errors or missing paperwork. This guide walks you through the reasons claims are denied, how to file an appeal, and what to do if your appeal is not successful.

Common Reasons for Dental Claim Denials

Understanding why your claim was denied is the first step toward a successful appeal. The denial notice or Explanation of Benefits (EOB) from your insurance company should include a reason code or explanation. Here are the most common reasons dental claims are denied:

• Procedure not covered: The specific dental procedure may not be included in your plan's list of covered services. Some plans exclude certain treatments like implants, orthodontics, or cosmetic procedures.
• Annual maximum exceeded: Most dental plans have an annual maximum, typically $1,000 to $2,000. Once you reach this limit, the plan will not pay for additional services until the next plan year.
• Pre-authorization not obtained: Some plans require pre-authorization (also called pre-determination) before certain procedures. If your dentist did not get approval before performing the work, the claim may be denied.
• Billing or coding errors: Dental procedures are identified by CDT (Current Dental Terminology) codes. If the wrong code is used, or if the claim form has errors, the insurance company may deny the claim. These errors are often correctable.
• Waiting period not met: Many dental plans have waiting periods, especially for basic and major services. If you have a procedure before the waiting period ends, coverage may be denied.
• Classified as cosmetic: The insurance company may classify a procedure as cosmetic rather than medically necessary. This is common with certain crown and veneer placements.
• Frequency limitation: Plans may limit how often certain procedures are covered. For example, a plan might cover one set of X-rays per year or one crown per tooth every five years.

Step 1: Review Your Denial Notice Carefully

When you receive a denial, start by reading the denial notice or EOB carefully. Look for the following information:

• The specific reason the claim was denied
• The procedure code and description listed on the claim
• The deadline for filing an appeal
• Instructions for how to submit an appeal
• Your plan's coverage terms for the denied service

If any information is unclear, call the number listed on your insurance card or on the EOB and ask a representative to explain the denial in detail. Take notes during the call, including the date, time, and the name of the person you spoke with.

Step 2: Gather Supporting Documentation

A strong appeal depends on good documentation. Before you submit your appeal, collect as much supporting evidence as possible. The goal is to show the insurance company that the procedure was medically necessary and should be covered under your plan.

Documentation to gather includes:

• Clinical notes from your dentist: These should describe the condition being treated, the diagnosis, and why the procedure was necessary.
• X-rays and photographs: Visual evidence of the dental condition can support your case.
• Letter of medical necessity: Ask your dentist to write a letter explaining why the procedure was medically necessary and not cosmetic.
• Your plan documents: Review your plan's Summary of Benefits and Coverage (SBC) to identify the language that supports your claim.
• Treatment history: Records of previous treatments for the same condition may help show that the denied procedure was part of an ongoing treatment plan.

Step 3: File an Internal Appeal

An internal appeal is the first formal step in challenging a denial. You are asking your insurance company to reconsider its decision. Under federal law, your insurer must have someone who was not involved in the original denial review your appeal.

To file an internal appeal:

1. Write a formal appeal letter: State your name, policy number, claim number, the date of the procedure, and the reason you believe the denial was incorrect. Be specific and factual.
2. Attach supporting documents: Include your dentist's clinical notes, X-rays, letter of medical necessity, and any relevant plan language.
3. Submit before the deadline: Most plans require internal appeals to be filed within 30 to 180 days of the denial. Check your denial notice for the exact deadline.
4. Send via certified mail or tracked submission: If you submit by mail, use certified mail with a return receipt so you have proof the appeal was received. Many insurers also accept appeals online or by fax.

The insurance company is generally required to respond to an internal appeal within 30 to 60 days for non-urgent claims. Keep a copy of everything you submit.

Step 4: Request an External Review

If your internal appeal is denied, you may have the right to an external review. In an external review, an independent third party who has no connection to your insurance company reviews the denial. This reviewer's decision is usually binding on the insurance company.

External review rights depend on your plan type:

• ACA-compliant plans: Plans that fall under the Affordable Care Act must offer external review. You typically have four months from the final internal appeal denial to request it.
• Employer-sponsored plans (ERISA): Many employer plans governed by the Employee Retirement Income Security Act also provide external review. Check your plan documents for details.
• Standalone dental plans: Some standalone dental plans may not be subject to ACA external review requirements. Your state insurance department can tell you whether external review is available for your specific plan.

To request an external review, follow the instructions in your internal appeal denial letter. The external reviewer will examine all the documentation from both sides and issue a decision, usually within 45 days.

Filing a Complaint with Your State Insurance Department

If you believe your insurance company is not following the terms of your plan or is not handling your appeal properly, you can file a complaint with your state insurance department. Every state has a department that oversees insurance companies and handles consumer complaints.

A state insurance department complaint can be filed at any point in the process, even before you complete the appeal steps. The department may:

• Investigate whether the insurer is following state laws and regulations
• Contact the insurance company on your behalf
• Help resolve the dispute
• Provide guidance on your rights and next steps

You can find your state insurance department through the National Association of Insurance Commissioners (NAIC) website at naic.org.

Tips for a Successful Dental Claim Appeal

Appeals that include strong documentation and clear reasoning are more likely to succeed. Here are practical tips to improve your chances:

• Act quickly: Do not wait until the deadline is near. Start gathering documentation and preparing your appeal as soon as you receive the denial.
• Be specific and factual: In your appeal letter, address the exact reason for the denial. Reference specific plan language that supports your position.
• Work with your dentist: Ask your dentist to provide a detailed letter of medical necessity and any clinical evidence that supports the need for the procedure.
• Check for coding errors: Ask your dental office to review the CDT codes used on the claim. A wrong code is one of the most common and easily fixable causes of denial.
• Keep copies of everything: Maintain copies of all correspondence, forms, and documents you send or receive related to the claim and appeal.
• Document phone calls: Note the date, time, representative's name, and what was discussed during any phone conversation with the insurance company.
• Stay persistent: Many claims are approved on appeal, especially when coding errors or missing documentation were the original cause. Do not give up after the first denial.

The Bottom Line

A denied dental insurance claim does not mean you are out of options. The appeals process exists to give you a fair chance to challenge a denial, and many claims are overturned, particularly when the issue was a billing error or missing documentation. Start by understanding why the claim was denied, gather strong supporting evidence, and file your appeal promptly.

If your internal appeal is unsuccessful, you may be able to request an external review or file a complaint with your state insurance department. Understanding your rights and being organized throughout the process are the keys to a better outcome. For more on how dental coverage works, see our guide on how dental insurance works.

This article is for educational purposes and does not constitute legal advice. Appeal timelines and rights vary by plan type and state. Contact your insurance company, your state insurance department, or a consumer advocacy organization for guidance specific to your situation.