Denial reason · Coverage
Dental or vision boundary
Do this first
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Your medical plan says the care belongs to your dental or vision plan, and the dental or vision plan may say it belongs to medical. Get both answers in writing and compare each to the plan's own wording.
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- Who has to act first
- You. Neither plan will sort this out for you. You ask each one for its written decision and the plan wording behind it, and the provider's billing office submits the claim to the right plan.
- Can it go to external review?
- Rarely. This is usually fixed another way. A plain boundary between two benefits is a plan-terms question and rarely qualifies for independent review. If the dispute becomes whether the service is medically necessary treatment of a medical condition, that is a medical judgment the reviewer may take up.
Wording you may see on your letter
- Dental services are not covered under your medical plan
- This service should be submitted to your dental plan
- Routine vision exam is not a covered medical benefit
- Please submit to your vision carrier
What it means
Many people have a medical plan and a separate dental plan, a separate vision plan, or both, often from different companies. Some care sits on the border: treating an infection or injury in or around the mouth, or an eye problem that comes from a disease like diabetes. Each plan can say the other should pay.
Stand-alone dental and vision plans generally do not have the federal surprise-billing protections. This site has not verified how the appeal rules apply to stand-alone dental and vision plans, so check the notice from that plan. It should tell you how to appeal.
Who has to act first
You do. Get a written decision from each plan. Ask each one which benefit it believes covers the service and why, and ask it to name the specific plan provision it used. The notice must state the specific reason and the plan provisions relied on.
Ask the provider’s billing office which kind of claim it sent and to which plan, and ask it to resubmit if it went to the wrong one.
You have at least 180 days after you receive a denial notice to file the first appeal with a medical plan covered by the federal claims rules. Your plan may allow more. Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different, often shorter, deadlines. Check the date on your notice, which controls.
Arguments that work
- Read the exclusion. Find the dental or vision exclusion in the medical plan document, and see whether its words cover this service. Ask what the plan means by “dental” or “vision.”
- Treating a medical condition. If the service treats an infection, an injury or a disease, not routine care, say so and have your doctor say so in writing. A medical necessity argument is a different argument from a coverage one, and the plan must explain its clinical reasoning if it denies on medical grounds.
- The other plan’s denial. If both plans refuse, show each the other’s denial and ask each to reconsider in writing.
- Specific reasoning. Ask for the criteria or guideline the plan relied on. If it relied on an internal rule, the notice must set it out or say a copy is free on request.
- A regulator. If you are stuck between two plans, complain to the state insurance department for an insured plan or the Employee Benefits Security Administration (1-866-444-3272) for a private employer plan.
Evidence to gather
- Both denial notices (you).
- The relevant plan documents with the dental or vision exclusion and definitions (each plan).
- Your doctor’s note on the diagnosis and why the service is needed (your doctor).
- The claim forms that were sent, and where (the provider’s billing office).
- A call log (you).
What to send
Send the medical plan a written appeal that quotes its own wording and attaches your doctor’s note and the other plan’s denial. Use the not-a-covered-benefit appeal letter. Ask for the decision in writing.
When this is not worth an appeal
If the service is routine dental or vision care that both plans clearly exclude and your records show no medical condition, an appeal has little to argue. Ask the provider about the cash price and a payment plan, and ask whether it offers financial assistance.