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Billing & claims · Last verified 2026-08-31
Independent publisher
Two different letters: the enrollee's appeal, which needs written consent, and the practice's own payment dispute, which is not an appeal at all.
Plan type: State Medicaid dental managed care plan (MCO, PIHP, or PAHP).
Before this letter can be sent
6 paragraphs included — 2 withheld — written as the enrollee's appeal, filed by this office with written consent
[PRACTICE NAME] [PRACTICE ADDRESS] [PRACTICE PHONE] [DATE] [PLAN NAME] - Appeals / Provider Dispute Department [APPEALS ADDRESS FROM THE NOTICE] Re: Appeal of an adverse benefit determination - Medicaid managed care Patient: [PATIENT NAME] - DOB: [DATE OF BIRTH] Member/subscriber ID: [MEMBER ID] - Plan: [PLAN NAME] Claim number: [CLAIM NUMBER] - Date(s) of service: [DATE OF SERVICE] Procedure code(s): [PROCEDURE CODES] - Amount billed: [BILLED AMOUNT] Denial notice dated: [DATE OF DENIAL NOTICE] - Denial code(s): [DENIAL CODES] This letter concerns the Medicaid dental claim identified above and the determination issued by notice dated [DATE OF DENIAL NOTICE]. This office files this appeal on behalf of the enrollee under 42 CFR 438.402(c)(1)(ii), which permits it only where state law allows and with the enrollee's written consent. The notice denies or limits authorization of a requested service, including the type or level of service. The determination described above is an adverse benefit determination within 42 CFR 438.400(b), and this letter is a request for appeal of that determination under 42 CFR 438.402. This office acts under 42 CFR 438.402(c)(1)(ii), which permits a provider to request an appeal on an enrollee's behalf where state law permits and with the enrollee's written consent. This office is not requesting continuation of benefits, which the same paragraph reserves to the enrollee. This appeal is filed within the 60 calendar days that 42 CFR 438.402(c)(2)(ii) allows from the date on the adverse benefit determination notice, which is dated [DATE OF DENIAL NOTICE]. 42 CFR 438.408(a) and (b)(2) require the plan to resolve this appeal as expeditiously as the enrollee's health condition requires and no later than 30 calendar days from receipt, extendable by up to 14 calendar days under paragraph (c)(1). Please confirm the date the decision is due. If the plan upholds the determination, please state in the notice of resolution the enrollee's right to request a state fair hearing and the deadline for doing so. Under 42 CFR 438.408(f)(1) that right arises only after this appeal is decided, and paragraph (f)(2) sets the state's request window at no less than 90 and no more than 120 calendar days from the notice of resolution. For the record: under 42 CFR 438.402(c)(1)(i)(A), where the plan fails to adhere to the notice and timing requirements in 42 CFR 438.408, the enrollee is deemed to have exhausted the plan's appeals process and may initiate a state fair hearing. Please confirm in writing the date this was received, the date the decision is due, and the name and credentials of the reviewer. Where the determination is upheld, please state the reason, the specific rule or contract provision relied on, and the next level of review with its deadline. Enclosures: - Copy of the notice of adverse benefit determination or remittance dated [DATE OF DENIAL NOTICE] - Copy of the claim as submitted, with attachments - ATTACH BEFORE SENDING: signed written consent from the enrollee authorizing this office to appeal on the enrollee's behalf Sincerely, [PROVIDER NAME, CREDENTIALS] [PRACTICE NAME] - NPI [NPI] - Tax ID [TAX ID] Before sending: read this letter against the denial notice and the patient's plan documents, replace every bracketed placeholder, and confirm the filing deadline and address printed on the notice itself.
A paragraph that does not apply is left out, never swapped for a weaker one.
A shared link carries the four selections only — never your words and never a patient detail. Every identifier stays a bracketed placeholder you fill inside your own practice-management system.
Every paragraph is a fixed string in this repository, written against one cited provision and carrying that citation on the page. The generator chooses which paragraphs apply to your selections, orders them, and joins them — it writes nothing of its own, draws no conclusion about your claim, and never softens or substitutes a paragraph whose conditions are not met. Where a paragraph does not apply it is listed as withheld, with the reason.
Citations were verified 2026-08-31 against the regulation, statute, or payer document linked beside each element. Provider contracts and plan documents override published manuals, so confirm the deadline and address on the notice you actually received.
Nothing you type here leaves your browser — the results are computed locally on this page.
A paragraph with no citation is marked as a request rather than an entitlement, because that is what it is.
| Element | What the rule gives | Authority and scope |
|---|---|---|
| This is an adverse benefit determinationAlways included | 42 CFR 438.400(b) defines an adverse benefit determination to include the denial or limited authorization of a requested service, the reduction, suspension, or termination of a previously authorized service, and the denial in whole or in part of payment for a service. The definition has seven prongs in all, and a payment denial solely for failure to meet the clean-claim definition is not one of them. | 42 CFR 438.400(b)(b), definitions (1)-(3) of sevenMedicaid managed care organizations, PIHPs, and PAHPs. Non-emergency medical transportation PAHPs are exempt from subpart F entirely. |
| Written consent and state-law permissionAlways included | If state law permits and with the written consent of the enrollee, a provider or an authorized representative may request an appeal or file a grievance, or request a state fair hearing, on behalf of an enrollee. | 42 CFR 438.402(c)(1)(ii)(c)(1)(ii)Both conditions are required. The same paragraph excepts continuation of benefits, which a provider cannot request. |
| Filed within the 60-day windowAlways included | An enrollee has 60 calendar days from the date on the adverse benefit determination notice in which to file a request for an appeal to the managed care plan. | 42 CFR 438.402(c)(2)(ii)(c)(2)(ii)The federal clock runs from the date on the notice. Some state manuals measure from the enrollee's receipt of it - quote whichever governs your route. |
| The plan's resolution clock | The plan must resolve a standard appeal as expeditiously as the enrollee's health condition requires and within a timeframe no longer than 30 calendar days from receipt, extendable by up to 14 calendar days at the enrollee's request or where the plan justifies a delay in the enrollee's interest. | 42 CFR 438.408(a), (b)(2), (c)(1)(a); (b)(2); (c)(1)The 30 days is a ceiling on a state-established timeframe, not a floor. |
| What comes after this appeal | An enrollee may request a state fair hearing only after receiving notice that the plan is upholding the adverse benefit determination, and the state sets the request window at no less than 90 and no more than 120 calendar days from the plan's notice of resolution. | 42 CFR 438.408(f)(1) and (f)(2); 438.402(c)(1)(i)(f)(1); (f)(2); 438.402(c)(1)(i)A state may also offer an optional external medical review, which cannot be required before the fair hearing or used to deter it. |
| Deemed exhaustion on a missed notice or deadline | Where the plan fails to adhere to the notice and timing requirements of 42 CFR 438.408, the enrollee is deemed to have exhausted the plan's appeals process and may initiate a state fair hearing. | 42 CFR 438.402(c)(1)(i)(A)(c)(1)(i)(A); mirrored at 438.408(c)(3) and (f)(1)(i)Medicaid managed care. |
| The dispute route is the contract's, not subpart F'sAlways included | A provider's payment, pricing, recoupment, or contract dispute follows the managed-care contract and the state's Medicaid program rules. The federal enrollee-appeal rules do not create a provider payment-dispute process, and their deadlines do not govern one. | 42 CFR 438.402(c)(1)(ii), by exclusion(c)(1)(ii) - provider standing exists only for the enrollee's appealThe state layer supplies the real deadline: Texas HHSC requires a 30-calendar-day resolution of provider complaints; Ohio gives 30 calendar days after exhaustion to request External Medical Review. |
| The outcome requested | State the outcome asked for, so the plan cannot treat the letter as correspondence. | No citation — a request, not an entitlementStructural. |
42 CFR 438.402(c)(1)(ii) excepts continuation of benefits from what a consented provider may request; the enrollee has to file for it. The clock is also different from the appeal clock and much shorter: continuation must be requested by the later of 10 calendar days after the plan sends the notice or the intended effective date, and 438.420(b) requires all five conditions - a timely appeal, a termination, suspension, or reduction of a previously authorized service, services ordered by an authorized provider, an unexpired original authorization period, and a timely continuation request. If the final decision is adverse the plan may recover the cost of the continued services, consistent with the state's usual recovery policy and the contract.
42 CFR 438.420 (eCFR, current text)42 CFR 438.402 (eCFR, current text)
The definition at 42 CFR 438.400(b) has seven prongs, not three - it also reaches untimely service provision, a plan's failure to meet the resolution timeframes, rural one-MCO out-of-network denials, and financial-liability disputes. But a denial of payment solely because the claim did not meet the clean-claim definition at 42 CFR 447.45(b) is expressly not an adverse benefit determination, so it is a payment dispute rather than an appeal.
Non-emergency medical transportation PAHPs are exempt from subpart F entirely, and applicable integrated plans - dual-eligible special needs plans - follow 42 CFR 422.629 through 422.634 instead of these rules.
Federal law gives the 60-day clock to the enrollee. A practice's own dispute runs on the plan contract and the state program: Texas HHSC requires its dental contractor to resolve provider complaints within 30 calendar days and the contractors' claim-appeal windows run 120 days from different instruments; Ohio's External Medical Review is 30 calendar days after the plan's internal process is exhausted, medical necessity only; California runs a Claim Inquiry Form at six months before a 90-day appeal from the EOB. Read the state note below for the route you are on, then read the contract.
HHSC Dental Services Contract No. HHS0002879, Attachment ACareSource Provider Manual - Ohio MedicaidMedi-Cal Dental Provider Handbook, Section 2
The federal 60-day clock belongs to the enrollee. A practice's own dispute runs on the plan contract and the state program, and those differ by state and by plan.
Texas
Enrollee appeal: Both Texas dental contractors run the consented enrollee appeal at 60 days, though they measure it from the member's receipt of the notice of action while the federal rule measures it from the date on the notice. Quote whichever one governs the route you are on.
Provider dispute: HHSC's own Dental Services Contract requires the Dental Contractor to resolve provider complaints within 30 calendar days of receipt. Claim appeals run 120 days, but keyed to different instruments by route: DentaQuest measures from the date of disposition of the Explanation of Benefits, MCNA from its initial claim determination, and traditional fee-for-service from the disposition date on the R&S Report.
HHSC Dental Services Contract No. HHS0002879, Attachment ADentaQuest, TX HHSC Dental Services Provider Office Reference Manual v9.6MCNA Dental Provider Manual: Texas Medicaid and CHIP
Florida
Enrollee appeal: AHCA states that an adverse benefit determination must be made within 7 days and may be appealed by the enrollee within 60 days, and that the state fair hearing follows 120 days after the plan appeal. That 60-day figure is AHCA's program-level statement; confirm it against the notice of adverse benefit determination the enrollee actually received.
Provider dispute: Use the plan's own provider complaint process first, then escalate to AHCA. AHCA states that where the issue involves a Medicaid managed care plan the provider should use the plan's process before submitting a complaint to the Agency, and that complaints are worked by the urgency of the reported issue rather than the order received. The Medicaid Helpline is 1-877-254-1055.
AHCA, SMMC Program Snapshot: Process for Enrollee Grievances and AppealsAHCA, SMMC Plan Poster (as of 02-04-2025)AHCA, Florida Medicaid providers: how to file a complaint
Ohio
Provider dispute: A provider who has exhausted an Ohio Medicaid managed care plan's internal appeal or claim-dispute process has 30 calendar days from the written notice that the process is complete to request an External Medical Review with Permedion, now a Gainwell Technologies business. A provider who skips the internal step has no EMR right at all.
CareSource Provider Manual - Ohio Medicaid (ODM approved 10/24/2025)Buckeye Health Plan, External Medical Review (EMR)
California
Enrollee appeal: A state hearing request is due within 90 days after the order or action complained of for fee-for-service. For a member enrolled in a Medi-Cal managed care plan the sequence differs: appeal the adverse benefit determination to the plan first, then request the hearing within 120 calendar days.
Provider dispute: The provider's first step is a Claim Inquiry Form within six calendar months of the Explanation of Benefits date. The first-level appeal is a letter to Medi-Cal Dental within 90 days of the EOB denial date - not a CIF, and not measured from a RAD. DHCS acknowledges within 21 calendar days, issues findings within 30 days, and may take up to 60 days where the matter is referred to Professional Review. After that, a writ of mandate under Welfare and Institutions Code section 14104.5 is the exclusive remedy, within one year.
Medi-Cal Dental Provider Handbook, Section 2 Program Overview (rev. September 2026)Medi-Cal Dental Provider Handbook, Section 4 Treating Members (rev. September 2026)Cal. Welfare and Institutions Code section 10951 (leginfo)
New York
Enrollee appeal: An enrollee has 60 calendar days from the date of the initial adverse determination notice to ask for a plan appeal. A standard plan appeal decision is due within 30 calendar days; a fast-track appeal within 2 working days and no more than 72 hours. After a Final Adverse Determination, the enrollee has 120 calendar days to ask for a state fair hearing through the Office of Temporary and Disability Assistance.
NYSDOH Medicaid Managed Care Model Member Handbook (rev. 8/19/2025)
There is no input anywhere in this tool for a patient name, a member ID, a claim number, or a date. The letter emits these tokens and you fill them inside your own practice-management system.
[DATE] — Today's date[APPEALS ADDRESS FROM THE NOTICE] — Appeals address, exactly as printed on the denial notice[PRACTICE NAME] — Practice name[PRACTICE ADDRESS] — Practice address[PRACTICE PHONE] — Practice phone[PATIENT NAME] — Patient or enrollee name[DATE OF BIRTH] — Date of birth[MEMBER ID] — Member or subscriber ID[PLAN NAME] — Plan or group name[CLAIM NUMBER] — Claim number[DATE OF SERVICE] — Date(s) of service[PROCEDURE CODES] — Procedure codes billed[BILLED AMOUNT] — Amount billed[DATE OF DENIAL NOTICE] — Date on the denial notice[DENIAL CODES] — Denial codes from the remittance[PROVIDER NAME, CREDENTIALS] — Treating provider[NPI] — Provider NPI[TAX ID] — Practice tax IDABA Task Force on the Model Definition of the Practice of LawABA Task Force, Report to the House of Delegates (August 2003)
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