ERISA dental appeal letter

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An ERISA group health plan - which includes employer dental benefits - must give a claimant at least 180 days after receiving an adverse benefit determination notice in which to appeal, under 29 CFR 2560.503-1(h)(3)(i). The review must be de novo: paragraph (h)(3)(ii) requires a review that affords no deference to the initial determination, conducted by an appropriate named fiduciary who is neither the individual who made that determination nor that individual's subordinate. Where the denial turns in whole or in part on a medical judgment, (h)(3)(iii) requires the fiduciary to consult a health care professional with appropriate training and experience in the field of medicine involved in the medical judgment, and (h)(3)(v) bars using the professional consulted on the initial denial or that person's subordinate. The claimant may submit written comments, documents, records, and other information under (h)(2)(ii), and may obtain the relevant claim documents free of charge under (h)(2)(iii) with relevance defined at (m)(8). The notice on review must state the internal rule relied on, or that a copy is available free on request, at (j)(5)(i), and must give the scientific or clinical judgment explanation for a necessity or experimental denial at (j)(5)(ii). Initial post-service decisions are due within 30 days with one 15-day extension under (f)(2)(iii)(B); pre-service decisions within 15 days with one 15-day extension under (f)(2)(iii)(A). If the plan fails to establish or follow procedures consistent with the regulation, (l)(1) deems the administrative remedies exhausted and the claimant may pursue remedies under ERISA section 502(a).