You’ve done everything right.

You submitted a pre-authorization, received confirmation that the procedure was covered, verified that the patient had available benefits under their annual maximum—and yet, when the claim is submitted, the insurance company denies it.

Sound familiar?

It’s a frustrating and unfortunately common scenario in dental practices. When this happens, both you and your patient are left wondering: What’s the point of a pre-authorization if it doesn’t guarantee payment?

Let’s unpack your options—and the patient's—for holding the insurance plan accountable and pushing for payment.

First, Understand What Pre-Authorization Really Means

A pre-authorization (also called a pre-determination or pre-treatment estimate) is not a guarantee of payment—something insurers love to point out in the fine print.

However, it does indicate that the treatment appears to be covered, assuming:

• The patient is still eligible at the time of service,

• The benefits are available,

• No policy changes have occurred.

So when a claim is denied despite meeting these conditions, you have a legitimate reason to challenge the decision.

Step-by-Step: What You Can Do When a Pre-Authorized Claim Is Denied

1. Review the Denial Explanation Carefully

Start by examining the Explanation of Benefits (EOB) or denial letter. Common reasons for denial include:

• “Treatment not medically necessary”

• “Policy exclusions”

• “Coverage terminated”

• “More information needed”

Compare the denial reason against the pre-authorization approval and the patient’s policy details.

2. Call the Insurance Plan Immediately

Speak to a representative and ask for:

• A detailed explanation of the denial,

• A copy of the patient’s full benefit plan, and

• Clarification on why the service is being denied after a pre-authorization approval.

Take notes, including the rep’s name, reference number, and call date/time.

3. Request a Reconsideration or Appeal

If you believe the claim should be paid:

• Submit a formal appeal, attaching:

  • A copy of the pre-authorization letter,

  • Clinical notes,

  • Radiographs or photos,

  • A narrative if needed,

  • A letter requesting reconsideration based on prior approval and available benefits.

Use strong, professional language. Here’s a sample you can modify:

“This claim was submitted with the understanding that pre-authorization confirmed coverage, the patient’s benefits were available, and no policy limitations were in effect. Based on these conditions, we are requesting immediate reconsideration and payment in accordance with the pre-determination.”

4. Involve the Patient

Encourage the patient to:

• Call their insurance company and ask for a written explanation,

• File their own appeal—insurers are often more responsive when patients get involved,

• Submit a complaint to their state department of insurance if the appeal is denied unfairly.

Many patients don’t realize they can take action—and may assume it’s the provider’s responsibility alone. Empower them with scripts and support.

Other Tools You Can Use

State Insurance Regulators

If the insurer continues to deny without justification, the patient (or you on their behalf, with permission) can file a complaint with the state insurance commissioner. This is especially powerful when:

• The denial contradicts a pre-authorization,

• The plan is fully insured and subject to state regulation.

Tip: Self-funded (ERISA) plans are governed federally. In those cases, patients must escalate through the U.S. Department of Labor.

Balance Billing (with caution)

If the patient’s plan is out-of-network and payment is denied, you may have the legal right to bill the patient. However, consider the patient relationship, documentation, and whether it’s worth pursuing.

If you're in-network, balance billing may not be permitted under your contract—so always verify.

Final Thoughts

A denied claim after pre-authorization isn’t just frustrating—it undermines trust in the dental insurance process. But as a provider, you have tools to fight back, protect your patients, and demand fair treatment.

Don't accept denials at face value. Challenge them. Appeal them. Educate your patients. Insurance companies count on providers giving up after a single “no.” When you push back with persistence and documentation, they often pay up.

Need help drafting an appeal letter or coaching patients on their complaint? Let me know—I'd be happy to provide templates.

Benjamin Tuinei

Founder - Veritas Dental Resources, LLC
Phone: 888-808-4513

Services:
PPO Fee Negotiators | PPO Fee Negotiating | Insurance Fee Negotiating
Insurance Credentialing | Insurance Verifications

Websites:
www.VeritasDentalResources.com | www.VerusDental.com