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.
Notice of Privacy Practices: What Does it Mean?
Date
Patient Street Address City, State Zip
Dear Patient:
Recently at our dental practice you received and signed a Notice of Privacy Practices. This form explains our office’s privacy practices, our legal duties, and your rights regarding your protected health information (PHI). It tells you about the ways we can use your PHI, and who has the right to access it. It also tells you how you can look at or get copies of your health information.
We do our best to keep all of our patients’ protected health information safe. If you have any questions about our privacy policies, please talk to our Privacy Officer, [Privacy Officer’s name], at [office number]. Thanks again for letting us provide you with the best in dental care.
Sincerely,
Dentist
Date
Patient Street Address City, State Zip
Dear Patient:
We value our patients, and want to do all we can to control costs. I am pleased to let you know about our new payment options, which will help provide you and your family with payment options so you can receive the dental treatment you need.
To help keep your costs low, our dental office will be using a new payment policy. You may pay for treatment with one of the following plans:
1 The total sum of treatment is paid by check, credit card, or a healthcare credit card such as CareCredit®.*
2 The initial payment is 1/2 of the total sum. The balance is paid at the completion of the treatment.
3 The initial payment is 1/3 of the total sum. The balance is paid in two equal monthly installments.
4 The initial payment is 1/4 of the total sum. The balance is paid in three equal monthly payments.
If payment is not received by the [date] of each month, it is the office policy to add a late charge of $[amount] to the balance.
If you have a dental benefit plan, you can authorize the insurance company to pay us, and we will let you know about the balance of the bill. We appreciate your understanding of this policy. We look forward to continuing to serve you and your family’s dental health needs!
Sincerely,
Dentist
* Subject to availability/approval
Date
Patient Street Address City, State Zip
Dear Patient:
Our office works hard to keep costs down, and has not changed its fees since [date]. However, due to rising costs, we must increase our fees by [percent amount] percent to keep our high standards of care. To help you, we offer many different payment plans to make it easier to pay for dental care.
For your convenience, our office offers the following payment plans:
1 The total sum of treatment is paid by check, credit card, or a healthcare credit card such as CareCredit®.*
2 The initial payment is 1/2 of the total sum. The balance is paid at the completion of the treatment.
3 The initial payment is 1/3 of the total sum. The balance is paid in two equal monthly installments.
4 The initial payment is 1/4 of the total sum. The balance is paid in three equal monthly payments.
Thank you for your continued support of our office. Please call us at [office number] if you have any questions.
Sincerely,
Dentist
* Subject to availability/approval
