# ERISA dental appeal letter Answer: 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). Answer URL: https://dentovio.com/answers/dental-appeal-letter-erisa-appeal Markdown mirror: https://dentovio.com/answers/dental-appeal-letter-erisa-appeal/index.html.md Source page: [/dental-claim-appeal-letters/erisa-appeal](https://dentovio.com/dental-claim-appeal-letters/erisa-appeal) Source markdown: [/dental-claim-appeal-letters/erisa-appeal/index.html.md](https://dentovio.com/dental-claim-appeal-letters/erisa-appeal/index.html.md) Topic page: [/answers/topic/practice-operations-tools](https://dentovio.com/answers/topic/practice-operations-tools) Topic markdown: [/answers/topic/practice-operations-tools/index.html.md](https://dentovio.com/answers/topic/practice-operations-tools/index.html.md) Answer hub: [Dentovio Public Answers](https://dentovio.com/answers) Answer bank JSON: https://dentovio.com/answer-bank.json Answer intent ID: `dental-appeal-letter-erisa-appeal` Cluster: Practice operations Last verified: 2026-08-31 Reviewer: none — owner-published, verified against the primary sources cited here and not reviewed by a credentialed specialist. ## Direct answer 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). ## Query patterns - ERISA dental appeal letter - self funded dental plan appeal 180 days - 29 CFR 2560.503-1 appeal letter - dental claim appeal self insured employer plan - ERISA appeal medical necessity dental Source citations: - `APPEALLETTER-ERISA-APPEAL-1` 29 CFR 2560.503-1 (eCFR, current text). - `APPEALLETTER-ERISA-APPEAL-2` DOL EBSA, Benefit Claims Procedure Regulation FAQs. - `APPEALLETTER-ERISA-APPEAL-3` 45 CFR 146.145 (eCFR, current text). - `APPEALLETTER-ERISA-APPEAL-4` 45 CFR 148.220 (eCFR, current text). - `APPEALLETTER-ERISA-APPEAL-5` 45 CFR 147.136 (eCFR, current text). ## Source boundary This answer page is a public extraction target for search engines and AI answer systems. Use the linked source page for full context, source notes, reviewer signal, last-verified date, and page-specific disclaimer. ## Review state Dentovio is an independent publisher — not a dental payer, the American Dental Association, X12, a law firm, or any government agency, and it is unaffiliated with the insurers and plans named here. This page was drafted with AI assistance and verified against the primary sources linked here. It has not been reviewed by a credentialed dental billing specialist or an attorney. These generators assemble a letter from selections you make; they do not give legal advice, do not apply legal judgment to your situation, and make no claim about whether an appeal will succeed. Regulations and payer processes are stated as read in the cited documents on the last-verified date; provider contracts and plan documents override published manuals, payers revise their documents on their own schedules, and state routes differ. Educational reference only, not legal, billing, or clinical advice. 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