Most insurance companies provide their customers with a booklet that details the coverage in their particular plan. It is important to read your booklet carefully so that you understand what kinds of procedures are covered and, more importantly, which procedures are not covered. In the event your dental insurance company refuses to pay for a procedure that you believe to be covered under your plan, you can write a dental insurance appeal letter.
Format and Content
A dental insurance appeal letter format should include the verbiage in your coverage booklet that makes you believe the procedure should be covered. Secondly, ask the dentist’s office staff to give you copies of your records, including any x-rays and reports that support your claim that the procedure should have been covered. It is very important to contact the insurance company to determine the correct address, department and person to whom appeals should be sent. Also include your policy, group and claim numbers in your appeal letter.
In this case, a patient needed a root scaling due to gingivitis and loss of some soft tissue around the teeth. The dentist’s office personnel contacted the patient’s insurance company and got the procedure pre-authorized. After the procedure, when the dentist’s office filed the patient’s insurance, the insurance company denied the procedure and refused to pay for it. The patient did some research and wrote this dental insurance appeal letter sample.
I am writing to appeal the denial of my claim number 789 for my root scaling procedure that was performed on September 3, 2013. The denial states that the procedure was not medically necessary. First of all, Karen Jones, who works for my dentist, Dr. Sherry Grant, contacted the insurance company and received a pre-authorization for the procedure. That document, including the pre-authorization number 3579 is attached. Secondly, I made a copy of the page out of my dental insurance handbook which clearly shows the circumstances under which a root scaling is covered.
According to your coverage details, a root scaling is a covered procedure when gingivitis is present and there is evidence of loss of soft tissue surrounding the teeth. My x-rays and other records from my dentist are attached. The records clearly show that gingivitis is present in my gums and there has been some soft tissue loss around my teeth. I have also included a letter from my dentist explaining why, in her expert opinion, the root scaling procedure was medically necessary and what the consequences would be of not performing the procedure. Those consequences include further loss of soft tissue surrounding the teeth and eventually loss of teeth.
Please consider my appeal and pay for my root scaling procedure as it is included in my plan and the procedure was pre-authorized and medically necessary.