Appealing a Denied Dental Claim: Step-by-Step Guide

Understanding Your Denial (Read the EOB)

When a dental insurance claim is denied, the first step is to carefully review the Explanation of Benefits (EOB) provided by the insurer. The EOB details why the claim was denied, referencing specific CDT codes, plan limitations, missing information, or lack of medical necessity. Take note of denial codes and remarks—these are critical for crafting a targeted appeal. If the EOB is unclear, contact the insurance company for clarification before proceeding.

Gathering Supporting Documentation

Successful appeals rely on thorough documentation. Gather all relevant records, including:

• Detailed clinical notes and chart entries
• Radiographs, intraoral photos, or diagnostic images
• Original claim forms and any prior correspondence
• Copy of the patient’s insurance card and benefits breakdown
• Relevant CDT codes and narratives justifying the procedure

Ensure that all documentation clearly supports the medical necessity or contractual coverage of the denied service. Organize these materials logically to streamline the appeal process.

Writing an Effective Appeal Letter

An effective appeal letter is concise, factual, and tailored to the specific denial reason. Address the letter to the insurer’s appeals department and include:

• Patient and provider information
• Claim number and date of service
• Specific reason for denial (as stated on the EOB)
• Clear explanation of why the claim should be reconsidered, referencing clinical findings and supporting documentation
• Attached evidence (x-rays, narratives, chart notes, etc.)

Use professional language and reference the patient’s policy language when applicable. If the denial was due to missing information, highlight the newly provided details. For medical necessity denials, emphasize how the treatment aligns with accepted dental standards and the patient’s health needs.

Follow-Up: What to Do After Submitting an Appeal

After submitting your appeal, track its status diligently. Document the date sent, method of submission (fax, mail, portal), and any confirmation numbers. Set reminders to follow up with the insurer within 10-15 business days. Keep detailed records of all communications, including names, dates, and outcomes of phone calls. If the appeal is approved, verify that payment is posted to the patient’s account and adjust AR accordingly. If denied again, review the new EOB for next steps.

When to Consider External Review or Arbitration

If internal appeals are exhausted and you believe the claim was wrongly denied, you may request an external review or arbitration. This process involves a third-party review of the claim and is governed by state and federal regulations. Consult the patient’s insurance policy for guidance on initiating external review. Be prepared to submit all prior documentation and correspondence. While not all claims qualify, this step can be crucial for complex or high-value procedures.

By following these structured steps and maintaining thorough documentation, dental offices and patients can significantly improve their chances of overturning insurance denials and ensuring proper reimbursement for necessary care.