# Medicaid dental appeal letter Answer: Federal law gives the appeal to the enrollee, not to the provider. Under 42 CFR 438.402(c)(1)(ii) a provider may request an appeal on an enrollee's behalf only if state law permits and with the written consent of the enrollee, and the same paragraph bars a provider from requesting continuation of benefits. The enrollee has 60 calendar days from the date on the adverse benefit determination notice to file the plan appeal (438.402(c)(2)(ii)); the plan must resolve a standard appeal as expeditiously as the enrollee's health condition requires and no later than 30 calendar days (438.408(a), (b)(2)), extendable by up to 14 calendar days (438.408(c)(1)). A state fair hearing comes only after notice that the plan upheld the determination (438.408(f)(1); 438.402(c)(1)(i)), with a state-set window of no less than 90 and no more than 120 calendar days from the resolution notice (438.408(f)(2)). Where the plan fails the notice and timing requirements the appeal is deemed exhausted and the enrollee may go straight to the fair hearing (438.402(c)(1)(i)(A)). Continuation of benefits is a separate, non-automatic request the enrollee must make by the later of 10 calendar days after the plan sends the notice or the intended effective date, and it requires all five conditions in 438.420(b); if the final decision is adverse the plan may recover the cost of continued services, consistent with the state's usual recovery policy and the contract (438.420(d)). A practice's own payment, pricing, recoupment, or contract dispute is not a subpart F appeal: it follows the managed-care contract and state program rules, whose deadlines differ - Texas HHSC requires the dental contractor to resolve provider complaints within 30 calendar days, and Ohio gives a provider 30 calendar days after exhausting the plan's internal process to request an External Medical Review on a medical-necessity denial. Answer URL: https://dentovio.com/answers/dental-appeal-letter-medicaid-managed-care-appeal Markdown mirror: https://dentovio.com/answers/dental-appeal-letter-medicaid-managed-care-appeal/index.html.md Source page: [/dental-claim-appeal-letters/medicaid-managed-care-appeal](https://dentovio.com/dental-claim-appeal-letters/medicaid-managed-care-appeal) Source markdown: [/dental-claim-appeal-letters/medicaid-managed-care-appeal/index.html.md](https://dentovio.com/dental-claim-appeal-letters/medicaid-managed-care-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-medicaid-managed-care-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 Federal law gives the appeal to the enrollee, not to the provider. Under 42 CFR 438.402(c)(1)(ii) a provider may request an appeal on an enrollee's behalf only if state law permits and with the written consent of the enrollee, and the same paragraph bars a provider from requesting continuation of benefits. The enrollee has 60 calendar days from the date on the adverse benefit determination notice to file the plan appeal (438.402(c)(2)(ii)); the plan must resolve a standard appeal as expeditiously as the enrollee's health condition requires and no later than 30 calendar days (438.408(a), (b)(2)), extendable by up to 14 calendar days (438.408(c)(1)). A state fair hearing comes only after notice that the plan upheld the determination (438.408(f)(1); 438.402(c)(1)(i)), with a state-set window of no less than 90 and no more than 120 calendar days from the resolution notice (438.408(f)(2)). Where the plan fails the notice and timing requirements the appeal is deemed exhausted and the enrollee may go straight to the fair hearing (438.402(c)(1)(i)(A)). Continuation of benefits is a separate, non-automatic request the enrollee must make by the later of 10 calendar days after the plan sends the notice or the intended effective date, and it requires all five conditions in 438.420(b); if the final decision is adverse the plan may recover the cost of continued services, consistent with the state's usual recovery policy and the contract (438.420(d)). A practice's own payment, pricing, recoupment, or contract dispute is not a subpart F appeal: it follows the managed-care contract and state program rules, whose deadlines differ - Texas HHSC requires the dental contractor to resolve provider complaints within 30 calendar days, and Ohio gives a provider 30 calendar days after exhausting the plan's internal process to request an External Medical Review on a medical-necessity denial. ## Query patterns - Medicaid dental appeal letter - 42 CFR 438.402 provider appeal on behalf of enrollee - Medicaid managed care dental denial appeal 60 days - dental provider Medicaid claim dispute letter - state fair hearing dental Medicaid Source citations: - `APPEALLETTER-MEDICAID-MANAGED-CARE-APPEAL-1` 42 CFR 438.400 (eCFR, current text). - `APPEALLETTER-MEDICAID-MANAGED-CARE-APPEAL-2` 42 CFR 438.402 (eCFR, current text). - `APPEALLETTER-MEDICAID-MANAGED-CARE-APPEAL-3` 42 CFR 438.408 (eCFR, current text). - `APPEALLETTER-MEDICAID-MANAGED-CARE-APPEAL-4` 42 CFR 438.420 (eCFR, current text). - `APPEALLETTER-MEDICAID-MANAGED-CARE-APPEAL-5` HHSC Dental Services Contract No. HHS0002879, Attachment A. - `APPEALLETTER-MEDICAID-MANAGED-CARE-APPEAL-6` CareSource Provider Manual - Ohio Medicaid. - `APPEALLETTER-MEDICAID-MANAGED-CARE-APPEAL-7` Medi-Cal Dental Provider Handbook, Section 2. ## 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. 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