Dental Insurance Appeal Letter – Step 1
Dental insurance appeal letter writing can help get a claim paid. When the office receives a dental claim denial, step one is to review the original claim. There are a few things to check first. Because the reason for denial may be unclear. Or the explanation of benefits might even misrepresent why a claim is denied. It may be necessary to call the insurance carrier to investigate the true reason behind the claim denial. But review all claim details first. And be sure there wasn’t a mistake on the original submission before moving forward.
Double check that the correct procedure codes are on the dental claim. And take a second look at the x-rays and the insurance narrative. Are the photos clear and clearly marked? Is there any obvious mistake or doubt. Think like an insurance claims adjuster for just a moment! Is there any reason to deny the claim? And does the denial make sense? Then, pick up the phone and double check on the denial. Be sure to record the date, time, and name of the insurance representative you speak with. And make a detailed note of the exact conversation. Ask why the claim is denied. Then, gather information on how to appeal the claim.
Dental Insurance Appeals Protocol
Each insurance company and carrier have different appeals processes. So be sure to ask the insurance representative what the process is. And know where to address the appeal. Also ask if there is a time limitation on the appeal. And if there are levels of appeal. There also may be a patient appeals process. Some insurance companies require the patient to appeal a dental claim denial.
The insurance company may have a website with appeal information as well. However, a phone call is still helpful to begin the process. Because many times the reason for denial is incorrect itself. Or there is information missing from the denial. Make that initial phone call for further explanation and clarification. This will be very helpful and worth the time and effort.
Dental Insurance Appeal Letter Components
Here are some components of a strong dental insurance appeal letter. This is a formal letter and request. So, let’s be sure to create an appeal letter that represents the practice well. And we also want to send a copy of this letter to our patient. Be sure to copy all documents, x-rays, and photographs in the first appeal to forward to our patient.
- Write the appeal letter on business letterhead (do not write a scribbled note on an explanation of benefits)
- Details matter: include today’s date, practice information, address, phone number – this is an official document
- Include patient’s name, date of birth, group number, member id#, claim reference number
- Use different narrative notes in appeal than was used on original claim and ask treating dentist for narrative in appeal
- Access benefit and coverage information no procedure codes and quote the insurance company’s verbiage
- Include supporting x-rays, photos, and perio-chart. Be sure all are clear and clearly marked
Dental Insurance Appeal Letter Template
Treating Dentist Name
Appeals Department (substitute as necessary)
Insurance Company Name
Insurance Company Address
RE: Patient Name
Patient’s Member ID
Claim Reference #
To Whom It May Concern,
Please accept this letter as an appeal to the recent denial of the above referenced claim for (patient name) on (date of service). Please see attached denial and explanation of benefits. It is my understanding based on this received denial and a follow-up phone conversation, that this claim was denied because (reason for denial).
This letter and appeal includes additional clinical information to support the patient’s needed dental procedure for your reconsideration. (Treating Doctor’s Notes Here). We also have information that dental benefits do exist for the denied procedure under this policy as quoted here (Dental Benefits Here).
Based on the information provided, please reconsider payment of this claim as soon as possible. I am available for any additional questions.
Treating Doctor’s Name
cc: patient name
Remember to follow-up on the appeal letter. Give it 30 days and the make another phone call. An insurance representative should be able to tell you that the letter was received. This is a good time to also call the patient to see if they have any new information on the appeal and reconsideration. As we always want our patients to know we are on top of every denial. And that we have their best interest at heart.
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Sometimes a patient must take the reins. And we can reach the end of what we are able to do for our patients. So, it’s always helpful to keep patients engaged from the very beginning. Be sure to gather accurate benefit information from the start. Because it can be futile to appeal a denial for a non-covered benefit. And it can also be embarrassing to tell our patient we had misinformation from the start. Promise only that you are on their side and will help in any way you can.