dental claim appeal letter

Sourced answer

Which letter a dental denial calls for depends on who funds the plan, and the four routes do not share a deadline, an authority, or even a claimant. A self-funded employer dental plan is governed by 29 CFR 2560.503-1: the claimant may demand the claim file free of charge under (h)(2)(iii) with relevance defined at (m)(8), and must be given at least 180 days to appeal under (h)(3)(i), with a de novo review by an independent named fiduciary under (h)(3)(ii) and, on a medical judgment, a consult with a professional trained in the field involved under (h)(3)(iii). A fully insured commercial plan follows the payer's own published process, and those differ sharply — Cigna publishes 180 calendar days nationally and 365 in California, Aetna runs 180 days to reconsideration then 60 to appeal (180 where the issue is medical necessity or experimental criteria), Delta Dental publishes a 90-day claim adjustment before any dispute, and Guardian publishes no appeal form at all. A Medicaid managed care denial belongs to the enrollee: 42 CFR 438.402(c)(1)(ii) lets a provider appeal on the enrollee's behalf only where state law permits and with written consent, on a 60-day clock, and expressly not for continuation of benefits; a provider's own payment dispute is not a subpart F appeal and runs on the contract instead. One guardrail crosses all four: a standalone dental plan is an excepted benefit under 45 CFR 146.145, so no letter should promise federal external review on it, though a state route may exist — Louisiana reaches dental claims over $250, while Illinois excludes dental-only policies outright.