Writing a Dental Insurance Appeal Letter: Example Included

Key Components of an Appeal Letter

When a dental claim is denied, submitting a well-structured insurance appeal letter can make all the difference. Successful appeals require clarity, accuracy, and supporting documentation. Here are the essential components every dental office should include:

• Patient and Provider Information: Include the patient's full name, date of birth, policy number, and the provider's NPI and contact details.
• Claim Details: Reference the original claim number, date of service, and relevant CDT codes for the procedures in question.
• Reason for Denial: Clearly state the denial reason as listed on the EOB (Explanation of Benefits).
• Appeal Justification: Provide a concise explanation of why the claim should be reconsidered, referencing clinical notes, radiographs, or other supporting documentation.
• Requested Action: Specify the outcome you are seeking, such as claim reprocessing or additional review.
• Attachments: List and include all relevant documents, such as clinical notes, x-rays, and a copy of the denied EOB.

Sample Dental Claim Appeal Letter

Below is a practical example of an insurance appeal letter that dental offices can adapt for their own use:

[Practice Letterhead]

Date: [Insert Date]

To: [Insurance Company Name]
Attn: Claims Appeals Department
[Insurance Company Address]

Re: Appeal for Claim Denial
Patient: [Patient Name]
DOB: [Patient Date of Birth]
Policy #: [Policy Number]
Claim #: [Original Claim Number]
Date of Service: [Date]
Provider: [Dentist Name, NPI #]

Dear Claims Appeals Reviewer,

We are writing to formally appeal the denial of claim #[Original Claim Number] for [Procedure Description, e.g., D4341 – Periodontal Scaling and Root Planing] performed on [Date of Service]. The EOB indicates the claim was denied due to [Denial Reason, e.g., "lack of clinical necessity"].

Upon review, we have included additional clinical documentation, including periodontal charting and radiographs, which demonstrate the medical necessity of the procedure per your policy guidelines. The patient presented with [brief clinical findings], and treatment was rendered according to the standard of care.

We respectfully request reconsideration and prompt reprocessing of this claim. Please find attached all supporting documentation for your review.

Thank you for your attention to this matter.

Sincerely,
[Practice Contact Name]
[Practice Phone Number]
[Practice Address]

Do's and Don'ts for Effective Appeals

• Do verify the denial reason and review the EOB carefully before drafting your appeal.
• Do use clear, professional language and reference specific CDT codes and clinical findings.
• Do attach all necessary documentation, such as clinical notes, x-rays, and the original EOB.
• Don't send appeals without double-checking patient and claim information for accuracy.
• Don't submit generic letters—tailor each appeal to the specific case and insurance carrier requirements.
• Don't delay—submit appeals within the insurer’s specified timeframe to avoid automatic denials.

Additional Resources for Appeals and Denied Claims

Staying organized and proactive is key to successful appeals. Maintain a tracking system for all denied claims and appeals, noting submission dates and follow-up actions. Regularly review payer guidelines for updates on appeal processes and documentation requirements. Consider developing template letters for common denial reasons, but always customize them for each case. Ongoing staff training in dental billing, CDT code updates, and insurance verification best practices will further strengthen your revenue cycle management and reduce future denials.