Dentists and their office teams are no strangers to the frustration of insurance denials, especially when the claim involves pre-authorized, covered services. When insurers deny claims despite confirming benefits in advance, the natural question is: Can citing state statutes or federal laws in your appeal make a difference?
The answer? Yes, when used correctly, legal references can strengthen your appeal narrative, especially when you’re dealing with clear overreach, bad-faith behavior, or systemic nonpayment tactics by the insurer.
Why legal citations can be effective
Insurance companies are regulated at both the state and federal levels. Referencing applicable laws:
- Elevates your appeal above the
generic “please reconsider” level - Signals to the payer that you know your rights
- Sets the groundwork for potential escalation to regulatory bodies or legal channels
This strategy is especially important when:
- Pre-authorization was granted and benefits were confirmed
- The denial contradicts written communication
- Denials appear to be based on vague, inconsistent, or unjustified reasons
Key legal references to consider
State insurance statutes
Each state has a Department of Insurance (DOI) and laws that regulate how insurers must operate. Common statutes include:
- Prompt payment laws: require insurers to pay or deny claims within a certain time frame.
- Unfair Claims Settlement Practices Act (UCSPA): prohibits insurers from misrepresenting facts or failing to honor pre-authorizations.
- Binding nature of pre-authorizations: some states recognize pre-authorizations as a form of written commitment from the insurer.
Example: California Insurance Code § 790.03(h): Lists unfair claims practices like “failing to settle claims promptly, where liability has become reasonably clear.”
Pro tip: Search “[Your State] Unfair Claims Practices Act dental insurance” to find relevant language.
Federal ERISA law
For many employer-sponsored plans, ERISA (Employee Retirement Income Security Act of 1974) governs plan administration.
Key points:
- Employers (plan sponsors) are fiduciaries who must act in the best interest of the beneficiaries.
- Patients (or their authorized representatives) can request a full explanation of the denial, including plan documents.
- If benefits are denied improperly, patients (or their legal reps) can sue under ERISA.
Useful reference: 29 US Code § 1133 – Claims procedure. Requires plans to provide specific reasons for denial and a clear appeals process.
Sample appeal narrative with legal references
Subject: Urgent Appeal – Claim Denial for Pre-authorized Covered Services
To Whom It May Concern,
We are submitting a formal appeal regarding the denial of Claim #123456 for [Patient Name], which included services previously pre-authorized on [Date] under Ref #7891011. Your documentation indicated these services were covered and payable.
Denying payment after confirming coverage undermines the purpose of pre-authorization and may violate applicable insurance regulations.
Specifically, under [State] law [Insert citation], insurers are prohibited from misrepresenting policy coverage or failing to honor prior authorizations.
Furthermore, if this is an ERISA-governed plan, we are requesting, under 29 U.S.C. §1133, a full explanation of denial, the specific plan provisions used in the determination, and the patient’s right to appeal.
We are requesting a prompt and fair reconsideration of this claim and payment of all covered benefits as originally confirmed. Failure to correct this denial may result in formal complaints to the [State Department of Insurance] and/or escalation under ERISA statutes.
Thank you for your attention to this matter.
Sincerely, [Doctor or Authorized Representative] [Practice Name and Contact Info]
Best practices for stronger appeals
Attach documentation:
- Copy of pre-authorization
- Chart notes, x-rays, clinical justification
- Benefit verification notes or screenshots
Include the patient in the process:
- Encourage them to call their insurance
- Have them sign a letter authorizing you to appeal on their behalf
Escalate when needed:
- Send to the insurance company’s appeals department and the medical director or dental director if possible.
- File a complaint with your state’s Department of Insurance if appeals are exhausted without resolution.
Keep records:
- Log all calls, faxes, and mailings
- Document reference numbers and representatives’ names
Final thought
While citing laws won’t guarantee a win, it shows you’re not an easy target. It signals professionalism, persistence, and awareness—traits that insurance companies often don’t want to spar with. You’re not just advocating for payment—you’re defending fair treatment of patients and providers alike.
If you’d like a customizable appeal template or a state-specific citation guide, I can help create those too—just let me know your location.
Editor's note: This article appeared in the June 2025 print edition of Dental Economics magazine. Dentists in North America are eligible for a complimentary print subscription. Sign up here.
