covered by more than one dental plan. For example, you may be covered by your employer’s plan and your spouse’s plan. When a patient has coverage under two or more group dental plans, there may be confusion as to how benefits are determined.
Certain rules are usually used when determining your benefits. There is no guarantee that any of the plans will pay for your services. It is important to consult your own plan for details regarding your coordination of benefits and coverage.
The following points should be considered when determining your coordination of benefits:
1 The coverage from both plans should be coordinated so that you or your dependent receives the maximum allowable benefit from each plan.
2 The aggregate benefit should be more than that offered by any of the plans individually, allowing duplication of benefits up to the full fee for the dental services received.
3 The plan that covers you first is your primary plan (most likely your employer-provided plan); all other plans are secondary. Secondary plans should only consider the benefits they have directly provided on your behalf when determining the balance of your dental benefits.
4 The secondary plan should use this benefit to pay up to 100 percent of your covered expenses during the claim period.
5 At the end of each claim determination, the secondary plan should provide you and the plan purchaser with a status report of claims paid and the remaining benefit.
6 When the patient is your dependent child, and the child is covered by two insurance plans, the plan of the parent whose birthday occurs first in a calendar year should be considered as primary.
7 When a determination cannot be made in accordance with “f” above, the plan that has covered the patient for the longer time should be considered as primary.
8 When one of the plans is a medical plan and the other is a dental plan, and a determination cannot be made in accordance with the above, the medical plan should be considered as primary.
Coordination of benefits can be difficult to understand. Please feel free to contact us [office number] if you have any questions.
Sincerely,
Dentist
Insurance Did Not Pay — Letter to Patient
Date
Patient Street Address City, State Zip
Dear Patient:
Thank you for your recent office visit. Our office has received partial payment for dental treatment from your insurance company for your procedure. Due to the limitations of your dental plan, only a part of the bill was covered. The balance of the payment is $[amount].
Please remit this amount to our office as soon as possible. If you have any questions, please contact your insurance carrier or our office at [office number].
Sincerely,
Dentist
Date
Patient Street Address City, State Zip
Dear Patient:
This letter is to inform you about recent changes in accepted insurance plans at our practice. As you know, in the past we have accepted dental benefit plans from [Insurance Carrier A]. However, as of [date], we will no longer accept plans from this company.
We will continue to accept dental benefit plans from the following insurance companies:
Insurance Carrier B Insurance Carrier C Insurance Carrier D Insurance Carrier E
We realize that this change may cause you some inconvenience, and we want you to continue choosing our practice for quality dental care. This may mean showing you how to fill out your own claim form to send directly to your insurance company or other administrative tasks. You can also talk about flexible payment arrangements with our financial coordinator, [financial coordinator’s name].
Once again, we are sorry for any problems this change may cause. If you have any questions or concerns about the change in insurance plans, please call our office at [office number].
Sincerely,
Dentist
Appeal of Claim Denial to Insurance Company — Letter from Patient
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
