Winning A Dental Insurance Appeal

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Before discussing the appeal process, it is necessary to discuss some of the basic issues that may lead to a dental claim denial in order to help you under which bill denials may be legitimate and which ones are worth contesting. Here are some areas to consider:

Errors happen

While the majority of dental insurance bills process smoothly, occasionally a dental plan may reject an invoice or reimburse the service at a level below the expectations of the plan enrollee. Thankfully, there is a process by which an enrollee can dispute a decision on the part of an insurance company. This process is typically referred to as an appeal.

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Reasons an Insurance Company May Not Pay Your Dental Bill

There are several reasons why an insurance company may refuse to pay a dental claim. Some of the more common reasons include situations where the dental service was:

  • Not covered by the dental plan’s benefits
  • Provided by an ineligible dentist or dental specialist
  • In excess of the plan’s maximum benefit
  • Received before the expiration of a waiting period

Not Covered: Dental plans are not standardized. Their coverage breadth can vary from only preventive care (e.g. annual check-ups and cleanings) to major care and orthodontics. If a service is not listed as covered (e.g. braces), the dental plan is not obligated to pay for the service.

Ineligible Provider: Some dental plans, such as HMOs and discount dental plans, restrict covered services to those delivered by in-network dental practices. Care received from an out-of-network dentist is uncovered.

Maximum Benefit: A maximum benefit is the annual dollar limit on insurance company spending for an enrollee’s dental care. Dental bills in excess of this amount, even for covered services, is the responsibility of the enrollee.

Waiting Period: A waiting period is a delay between the time a person enrolls in a dental plan and when the plan will cover a particular service. Some dental plans have waiting periods of six months to a year for expensive procedures such as a root canal.

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The No Surprises Act & Dental Insurance

“Surprise billing” is a phrase often used to describe medical bills where charges and fees are in excess of a patient’s reasonable expectations and are only partially paid by an insurer because one or more of the healthcare providers were out-of-network. The limited payment by insurer is called “balance billing” because it leaves a considerable balance to be paid by the patient. This balance billing can be exceptionally aggravating because:

  • A healthcare provider may not have identified him or herself are out-of-network and may not have provided the cost implications
  • Out-of-network care may be received within a facility that is otherwise in-network

While the “No Surprises Act” became effective January 1, 2022, the Centers for Medicare & Medicaid Services has clarified that the Act generally does not apply to dentists and dental insurance. Exceptions may arise in the context of >good faith estimates for dental services given to patients who uninsured or otherwise paid for the dental services without the assistance of dental coverage. Additional exceptions may occur with respect to dental care delivered in hospitals or emergency treatment

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How to Fight a Claim Denial or a Lower Reimbursement Decision

The first step in challenging a billing issue with an insurance company is to review the specific services listed on the bill (checking for any errors) and then cross-referencing the list with the services covered by your dental plan. If you no longer have your Explanation of Benefits document, you can visit the insurance company’s website to download it. If, for some reason, you cannot find it there, you should be able to call your insurance company’s customer service center to get assistance on the matter.

If you see that your medical bill correctly lists the service and your dental plan’s benefit explanation covers that service (without any of the issues mentioned in the “Reasons an Insurance Company May Not Pay Your Dental Bill” section), your next step is to call the insurance company’s claims department and explain the situation. Always keep a record of when you called the insurance (date/time) and with whom you spoke in the company. If the claims department does not remedy the matter over the phone, ask for information on the insurance company’s appeal process including any form you need to complete or website address you need to visit.

You’ll need to follow an insurance company’s appeal process carefully because you do not want to ignore a requirement that may allow the company to reject your appeal on a technicality. Technicalities may include incomplete appeals form, not sending the form to the correct insurance department, not filing the appeal within a given amount of time from the date of the claim denial.

In some cases, you may need to go back to your dentist to obtain additional information needed for the appeal. For example, the insurance may request additional data on a tooth’s condition prior to treatment or x-rays to justify an expensive procedure such as a crown.

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What to Do if You Lose Your Appeal

If your appeal is denied and you still feel that you are in the right, you should contact your state’s Department of Insurance and explain the situation. If they are unable to provide assistance, consider the use of a lawyer. However, you need to evaluate the cost of a lawyer as well as the possibility that your claim still may be denied. If you have limited economic resources, you may be able to find a legal clinic offering assistance at reduced rates or for free.

Local Departments of Insurance

Below is a state-by-state list of contact information for complaints to local Departments of Insurance.

State Department of Insurance
Website for Complaints
Phone Number
Alabama More Info 334-241-4141
8:00 am - 5:00 pm
Alaska More Info 907-269-7900
Arizona More Info 602-364-3100
Arkansas More Info 501-371-2600
8:00 am — 4:30 pm
California More Info 800-927-4357
Colorado More Info 800-930-3745
8:00 am - 5:00 pm
Connecticut More Info 860-297-3800
Delaware More Info 800-282-8611
District of Columbia More Info 202-727-8000
Florida More Info 877-693-5236
Georgia More Info 404-656-2070
Hawaii More Info 808-586-2790
between 7:45 am - 4:30 pm
Idaho More Info 208-334-4319
Illinois More Info 312-814-2420
Indiana More Info 800-457-8283
Iowa More Info 515-654-6600
8:00 am - 4:30 pm
Kansas More Info 800-432-2484
Kentucky More Info 502-564-3630
Louisiana More Info 800-259-5300
Maine More Info 800-300-5000
Maryland More Info 800-492-6116
Massachusetts More Info 617-521-7794
8:45 am - 5:00 pm
Michigan More Info 877-999-6442
Minnesota More Info 651-539-1600
Mississippi More Info 800-562-2957
Missouri More Info 800-726-7390
8:00 am - 5:00 pm
Montana More Info 800-332-6148
Nebraska More Info 877-564-7323
Nevada More Info 775-687-0700
New Hampshire More Info 800-852-3416
New Jersey More Info 609-292-7272
New Mexico More Info 505-827-4549
New York More Info 800-342-3736
North Carolina More Info 855-408-1212
North Dakota More Info 701-328-2440
Ohio More Info 800-686-1526
Oklahoma More Info 800-522-0071
Oregon More Info 888-877-4894
Pennsylvania More Info 877-881-6388
Rhode Island More Info 401-462-9520
from 8:30 am - 4:00 pm
South Carolina More Info 803-737-6180
South Dakota More Info 605-773-3563
Tennessee More Info 800-342-4029
Texas More Info 800-252-3439
Utah More Info 800-439-3805
Vermont More Info 800-964-1784
Virginia More Info 866-722-2551
Washington More Info 800-562-6900
8:00 am - 5:00 pm
West Virginia More Info 888-879-9842
Wisconsin More Info 800-236-8517
Wyoming More Info 307-777-7402

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