How to appeal a denied dental claim

A denied dental claim is not always final. You may be able to appeal the decision by addressing the denial reason and providing supporting records from your dental office. Start by reviewing the denial letter, gathering the needed documents and checking your plan’s appeal deadline. 

What you will learn in this article: 

• A denied dental claim may not be final; you can ask your insurer to review the decision again.

• Start by finding the exact denial reason and gathering your EOB, plan information and supporting dental records.

• A stronger appeal directly addresses the denial reason and includes records that explain why the treatment was recommended. 

• If the claim is still denied, check your plan for additional review options and ask your dental office about payment or financing options. 

If your dental claim was denied and you’re not sure what to do next, schedule an appointment with an Aspen Dental provider. Your care team can help you understand the denial, gather supporting records and review your options. 

Understand what the denial letter says 

Read the denial letter carefully. It must explain why your claim was denied. Every denial notice must include the reason for denial and information about how to appeal.¹ Common reasons include a service being listed as "not medically necessary," a missing pre-authorization or a code mismatch between what the dental provider submitted and what your plan covers. 

Write down the denial reason. You will need it at every step. 

Gather your documents 

Before you file anything, pull these together: 

• The denial letter itself 

• Your explanation of benefits (EOB) from the insurer 

• Your dental plan’s summary of benefits 

• Your dental provider’s treatment notes and X-rays 

• Any referral or pre-authorization forms 

According to the American Dental Association (ADA), records such as X-rays, photos, dental charts and a written explanation can help show why your dental provider recommended the treatment.² Ask your dental provider’s office for copies of anything you need. 

Request an internal appeal 

Start with an internal appeal. This means asking your insurer to review the decision again. Submit a written appeal letter and keep it short and factual. 

Your letter should include: 

• Your name, member ID and claim number 

• The date of service 

• The denial reason listed in the letter 

• Why you believe the service should be covered 

• A list of the records you attached

The ADA recommends explaining why your dental provider advised the treatment and including helpful records, such as X-rays, photos, dental charts or a short written note.³ Ask your dental provider to help you gather the records that apply to your care. 

Send everything by certified mail or through the insurer’s secure online portal. Keep a copy of every document you send. 

Know your deadlines 

Most plans require you to file within 180 days of the denial date.¹ Check your denial letter for the exact window your plan sets. Missing the deadline can close your right to appeal. Mark the date and move quickly. 

Request an external review if the internal appeal fails 

If your insurer still denies the claim after the internal appeal, you can ask for an external review. An independent organization reviews your case. They are not connected to your insurer. 

The U.S. Department of Labor notes that under federal law, most non-grandfathered health and dental plans must offer an external review option.¹ Some state laws offer additional protections. Contact your state insurance commissioner's office if you are unsure of your rights. 

The external reviewer's decision is usually binding on the insurer. 

How your dental care team can help 

Dealing with insurance paperwork on top of a dental concern is a lot. Many dental care teams are experienced in working through insurance questions with patients. A trained team member can review your EOB with you, help you understand what your plan covers and communicate directly with your insurer on your behalf. They can also help you understand payment and financing options if the appeal does not go your way. 

If you’re preparing an appeal, ask your dental care team to review your EOB and help identify the records that may support your claim. They can also help you understand payment options if the appeal is not approved. 

How to appeal a denied dental claim FAQs 

Still have questions about appealing a denied dental claim? These answers cover a few common concerns. 

How long does an appeal take? 

Internal appeals typically take 30 to 60 days.¹ Urgent appeals can be processed faster. Check your plan documents for the exact timeline your insurer follows. 

Can my dental provider file the appeal for me? 

Yes. Many dental offices file appeals on behalf of patients. Ask your dental provider's office if they offer this. They know the billing codes and the documentation your insurer needs. 

What if the treatment already happened? 

You can still appeal after treatment. Provide all treatment notes, X-rays and any pre-treatment estimates. The process is the same. 

Is there a cost to file an appeal? 

Filing an internal or external appeal is free.¹ You should never be charged just to request a review of your claim. 

What if I can't afford care while I wait? 

Talk to your dental provider's office. Ask about payment plans or financing options. Many offices can work with you so care does not have to wait on a paperwork outcome. 

Sources 

¹ U.S. Department of Labor, Employee Benefits Security Administration: "Filing a Claim for Your Health Benefits." https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/publications/filing-a-claim-for-your-health-benefits 

² American Dental Association: “How to File an Appeal.” https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/practice/dental-insurance/how_to_file_an_appeal.pdf 

³ American Dental Association: “Responding to Claim Rejections.” https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/practice/dental-insurance/responding-to-claim-rejections.pdf