Dental insurance in most states may have a requirement for a predetermination or prior approval of benefits. This is a type of claim that is filed prior to performing any type of dental procedure.
A predetermination may be requested by a dentist before services are performed. A predetermination or prior approval is not a requirement by any state or federal law.
Explanation of Benefits
When an insurer denies a claim, an explanation of benefits form will be sent to the insured with a reason why the claim was denied. This is also known as an adverse benefit determination. This form is sent to an insured within 30 days after an insured files a claim. If an insurer needs additional time to process a claim, an insurer will provide a reason within the 30-day window. This is because an insurer may require more information than was provided for the claim.
Request for Appeal
If an insured disagrees with the claim denial, an appeal can be filed with the insurer up to 240 days from the receipt of an explanation of benefits form. An appeal request needs to be sent to the insurer in writing stating why the insured thinks the claim decision was not correct. An insured should also send any other documentation that is necessary with the appeal request. The insurer will also send or make available to the insured any documents that are relevant to the denied claim.
Review Decision
When an appeal request is received by the insurer, a review of the appeal will be conducted and the insured will be notified in writing of the decision. This notification should be received by an insured within 60 days from receipt of the appeal request. If an extension is needed for the review, the insurer will send a written notice to the insured before the end of the 60-day period. This extension cannot exceed a second 60-day period from the end of the first 60-day period.
External Appeal
In the event that an insurer requires an external review of the claim appeal, a written request needs to be sent to the insurer. This needs to be done within 60 days from when the written notice of determination is received from the insurer. Some states may require an insured to pay up to 50 percent of the costs for the external appeal review. The insurer will pay the remainder of the cost. If an appeal is still denied, civil action can be taken under section 502(a) of the ERISA Act.