Your Guide to Crafting a Winning Dental Claim Appeal Letter Sample

Your Name
Your Address
Your City, State, Zip Code
Your Phone Number
Your Email Address

Date

Dental Insurance Company Name
Appeals Department
Address
City, State, Zip Code

Subject: Appeal of Denied Claim - Policy Number: [Your Policy Number] - Patient Name: [Patient's Name] - Claim Number: [Claim Number] - Date of Service: [Date of Service]

Dear Dental Insurance Company Appeals Department,

I am writing to formally appeal the denial of claim number [Claim Number] for services rendered on [Date of Service] to [Patient's Name]. The reason for denial stated was "medical necessity not met." I believe this decision is incorrect, and I am requesting a review of this decision.

The treatment I received, [Briefly describe the treatment, e.g., a root canal, a crown], was deemed necessary by my dentist, Dr. [Dentist's Name], to address [Explain the dental problem and why the treatment was necessary. Be specific. For example: "a severe tooth infection that was causing significant pain and risked spreading."]. I have attached a letter of medical necessity from Dr. [Dentist's Name] which further explains the clinical reasons for this procedure and why it was the most appropriate course of action for my oral health.

I have also included the following supporting documents:

• A copy of the original Explanation of Benefits (EOB) showing the denial.
• A letter of medical necessity from Dr. [Dentist's Name].
• Any relevant X-rays or diagnostic reports.

I kindly request that you re-evaluate my claim based on the provided information. Please feel free to contact me or Dr. [Dentist's Name] if you require any further clarification.

Thank you for your time and consideration.

Sincerely,
[Your Signature]
[Your Typed Name]

Your Name
Your Address
Your City, State, Zip Code
Your Phone Number
Your Email Address

Date

Dental Insurance Company Name
Appeals Department
Address
City, State, Zip Code

Subject: Appeal of Denied Claim - Incorrect Procedure Code - Policy Number: [Your Policy Number] - Patient Name: [Patient's Name] - Claim Number: [Claim Number] - Date of Service: [Date of Service]

Dear Dental Insurance Company Appeals Department,

I am writing to appeal the denial of claim number [Claim Number], submitted for services provided on [Date of Service] to [Patient's Name]. The denial was due to an incorrect procedure code being billed. I believe this is an error, and I am requesting a review and resubmission with the correct code.

My dentist, Dr. [Dentist's Name], performed [Briefly describe the treatment]. The submitted claim used procedure code [Incorrect Procedure Code]. However, the correct code for this procedure is [Correct Procedure Code]. This discrepancy seems to be an administrative error, not an indication that the service was not covered.

I have attached:

• The original Explanation of Benefits (EOB) showing the denial.
• A statement from Dr. [Dentist's Name]'s office confirming the correct procedure code and explaining the nature of the service.

I would appreciate it if you could review this claim and allow it to be resubmitted with the correct procedure code for proper adjudication. Please let me know if you need anything further from my end.

Thank you for your attention to this matter.

Sincerely,
[Your Signature]
[Your Typed Name]

Your Name
Your Address
Your City, State, Zip Code
Your Phone Number
Your Email Address

Date

Dental Insurance Company Name
Appeals Department
Address
City, State, Zip Code

Subject: Appeal of Denied Claim - Prior Authorization Issue - Policy Number: [Your Policy Number] - Patient Name: [Patient's Name] - Claim Number: [Claim Number] - Date of Service: [Date of Service]

Dear Dental Insurance Company Appeals Department,

I am writing to appeal the denial of claim number [Claim Number], related to services provided on [Date of Service] for [Patient's Name]. The denial notice indicated that prior authorization was not obtained for the procedure. I believe this is an oversight, as prior authorization was indeed sought and, in some cases, approved.

The treatment, [Briefly describe the treatment], required prior authorization. My dentist's office, Dr. [Dentist's Name]'s office, [Indicate what happened, e.g., "submitted the prior authorization request on [Date of Request] and received approval number [Approval Number]," or "believed the pre-authorization had been obtained but it appears there was a communication breakdown."]. I have enclosed documentation to support our efforts to obtain prior authorization.

Please find the following documents attached:

1. A copy of the original EOB with the denial.
2. A copy of the prior authorization request form, if available.
3. A written confirmation or approval number for the prior authorization, if applicable.
4. A statement from Dr. [Dentist's Name]'s office clarifying the prior authorization process.

I request that you review my claim again, taking into consideration the prior authorization information provided. Your prompt attention to this matter would be greatly appreciated.

Thank you for your reconsideration.

Sincerely,
[Your Signature]
[Your Typed Name]

Your Name
Your Address
Your City, State, Zip Code
Your Phone Number
Your Email Address

Date

Dental Insurance Company Name
Appeals Department
Address
City, State, Zip Code

Subject: Appeal of Denied Claim - Coverage Dispute - Policy Number: [Your Policy Number] - Patient Name: [Patient's Name] - Claim Number: [Claim Number] - Date of Service: [Date of Service]

Dear Dental Insurance Company Appeals Department,

I am writing to appeal the denial of claim number [Claim Number] for services provided on [Date of Service] to [Patient's Name]. The denial was based on the assertion that the service, [Briefly describe the treatment], is not a covered benefit under my dental plan. I disagree with this assessment and request a thorough review of my policy's coverage.

According to my understanding of my dental policy, specifically [Mention specific section or benefit, if known, e.g., "the benefits outlined for restorative dentistry"], the procedure performed by Dr. [Dentist's Name] should be covered. I have attached a copy of my policy document for your reference, highlighting the relevant sections. My dentist also provided information explaining why this treatment is necessary for my oral health and why it falls within covered services.

To support my appeal, I have included:

• The original Explanation of Benefits (EOB) showing the denial.
• A copy of my dental insurance policy document, with relevant sections marked.
• A letter from Dr. [Dentist's Name]'s office explaining the procedure and its coverage according to their understanding of dental insurance guidelines.

I urge you to re-examine my claim and policy to confirm coverage for this essential dental treatment. I am confident that upon review, you will find that this service is indeed covered.

Thank you for your prompt attention to this matter.

Sincerely,
[Your Signature]
[Your Typed Name]

Your Name
Your Address
Your City, State, Zip Code
Your Phone Number
Your Email Address

Date

Dental Insurance Company Name
Appeals Department
Address
City, State, Zip Code

Subject: Appeal of Denied Claim - Missing Information Correction - Policy Number: [Your Policy Number] - Patient Name: [Patient's Name] - Claim Number: [Claim Number] - Date of Service: [Date of Service]

Dear Dental Insurance Company Appeals Department,

I am writing to appeal the denial of claim number [Claim Number], submitted on [Date of Service] for services provided to [Patient's Name]. The denial notice stated that information was missing from the claim. I have now gathered the necessary documentation and am resubmitting it for your review.

The specific missing information was [Clearly state what information was missing, e.g., "a copy of the patient's dental history," or "detailed notes from the dentist regarding the diagnosis."]. My dentist's office has provided the requested information, and I have included it with this appeal.

Please find the following documents attached:

1. The original Explanation of Benefits (EOB) indicating the denial.
2. The complete documentation that was requested to support the claim, including [List the specific documents, e.g., "dental history records," "dentist's diagnostic notes," "any relevant treatment plans."].

I trust that with this additional information, my claim can be properly processed and approved. Please confirm receipt of these documents and advise on the next steps.

Thank you for your assistance.

Sincerely,
[Your Signature]
[Your Typed Name]

Your Name
Your Address
Your City, State, Zip Code
Your Phone Number
Your Email Address

Date

Dental Insurance Company Name
Appeals Department
Address
City, State, Zip Code

Subject: Appeal of Denied Claim - Duplicate Claim Correction - Policy Number: [Your Policy Number] - Patient Name: [Patient's Name] - Claim Number: [Claim Number] - Date of Service: [Date of Service]

Dear Dental Insurance Company Appeals Department,

I am writing to appeal the denial of claim number [Claim Number], dated [Date of Service], for services provided to [Patient's Name]. The denial notice indicated that this claim was a duplicate of a previously processed claim. I believe this is an error, as the claim has not been submitted or paid before.

It is possible that a similar claim was submitted in error or that there was a system glitch causing this misinterpretation. My dentist's office has confirmed that this is the only claim submitted for this specific service on this date. I have enclosed a statement from the dental office to clarify this situation.

To support my appeal, please find the following documents attached:

• The original Explanation of Benefits (EOB) showing the denial.
• A statement from Dr. [Dentist's Name]'s office confirming that this is not a duplicate claim and that it has not been previously processed or paid.

I kindly request that you investigate this matter and remove the "duplicate claim" status so that my claim can be properly evaluated and paid.

Thank you for your attention to this unusual situation.

Sincerely,
[Your Signature]
[Your Typed Name]

Your Name
Your Address
Your City, State, Zip Code
Your Phone Number
Your Email Address

Date

Dental Insurance Company Name
Appeals Department
Address
City, State, Zip Code

Subject: Appeal of Denied Claim - Incorrectly Denied Non-Covered Service - Policy Number: [Your Policy Number] - Patient Name: [Patient's Name] - Claim Number: [Claim Number] - Date of Service: [Date of Service]

Dear Dental Insurance Company Appeals Department,

I am writing to appeal the denial of claim number [Claim Number] for services provided on [Date of Service] to [Patient's Name]. The denial stated that the service, [Briefly describe the treatment], is considered a non-covered service. However, I believe this denial is incorrect, and I am requesting a review of your decision.

While I understand that some dental procedures may not be covered, my understanding of my policy, and the information provided by Dr. [Dentist's Name], is that this particular service, [Briefly describe the treatment], is considered medically necessary and falls within the scope of covered benefits. I have enclosed documentation from my dentist that explains the necessity of this treatment in relation to my overall oral health.

To assist in your review, please find the following documents attached:

1. The original Explanation of Benefits (EOB) showing the denial.
2. A letter from Dr. [Dentist's Name] detailing the procedure, its medical necessity, and why it should be considered a covered benefit under my plan.
3. Any relevant supporting medical records or diagnostic reports.

I kindly ask that you reconsider this claim based on the provided evidence. I am hopeful that a thorough review will result in the approval of this necessary dental treatment.

Thank you for your time and attention to this appeal.

Sincerely,
[Your Signature]
[Your Typed Name]