Читать книгу Dental Letters: Write, Blog and Email Your Way to Success with CD-ROM - American Dental Association - Страница 24

Date

Insurance Company Street Address City, State Zip

Re: Patient Patient Date of Birth Patient Insurance Policy Number Patient Insurance Policy Group Number Patient Insurance Claim Number

Dear [Insurance Company]:

I am writing to appeal the decision by [insurance company] to deny coverage of [name of service, procedure, or treatment].

The letter dated [date of denial letter] informed me that [insurance company] denied this claim because:

[Insert text from denial letter here]

According to my dental care provider, this treatment is medically necessary to treat the specific medical condition described below. It is not in any way for general health and is not for cosmetic purposes to improve appearance.

The treatment will, or is reasonably expected to, prevent the onset of an illness, condition, or disability. [Provide diagnosis details below.]

OR

The treatment will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects of an illness, injury, or disability. [Provide diagnosis details below.]

OR

I believe this decision was made in error. [State the correct information here. Was there a coding error? Are you being denied a procedure different from the one you requested?]

I wish to have my claim reviewed again and approved in a timely manner. Your letter did not indicate whether my claim had been reviewed by a dentist. If a dentist did review the claim, then the name and contact information of the dentist should be provided. This information is necessary so that my dental care provider may contact the dentist reviewer to discuss treatment decisions on a professional level.

I have attached the following documents to support my claim:

 A copy of the original denial letter

 A copy of the original explanation of benefits

 A copy of my original dental claim form

 A letter from my dental provider explaining the necessity of this treatment

 An explanation of treatment and services from my dental provider’s office

 A phone log of calls (including dates and the names of insurance personnel I spoke to) made to and received from the insurance company

 Applicable dental records [CAN INCLUDE X-RAYS, PHOTOGRAPHS, DIAGNOSIS NOTES FROM YOUR DENTIST, RECORDS OF TREATMENT, DIAGNOSTIC RECORDS INCLUDING CHARTS AND STUDY MODELS, REFERAL LETERS AND CONSULTATIONS WITH REFERING OR REFERAL DENTISTS AND/OR PHYSICIANS]*

I appreciate your prompt attention to this matter, and look forward to hearing from you.

Sincerely,

Patient

Enclosures

* These documents are examples of the types of things you may wish to include in your appeal letter. It is not necessary to include each of the documents listed, but the more information you can provide, the stronger your case for appeal will be.

When appealing a claim, it is important to follow the specific instructions provided by the particular carrier, including the submittal of the appeal in writing within the time allowed by the carrier. It is important to send it to the specified department of the carrier and must be in the form the carrier requires. It should prominently include the word “appeal” in the title and the text of the document and in any cover letter that accompanies the appeal document. If you have further questions, it is best to call the carrier directly.