Advice on How to Appeal a Denied Claim

Belle DuCharme, CDPMA, CDC

A word that strikes fear in every person’s mind that files insurance claims: DENIAL

How can this be?  You know you did everything right but now you have to appeal the claim.  To get paid you must put in time and accuracy to get results.

1.      Follow the appeal protocol of the insurance company that denied the claim.  Each company has its rules for appeals. Available from their website or there is usually information on the denial EOB on the bottom of the page.
2.      Construct a formal letter on your letterhead. No hand written notes on the EOB or original claim.
3.      Don’t skip the details on the letter.  Your full address, phone and email contact information; the patient’s full name, address, phone number, date of birth, Member ID, claim # or and check # and also a reference number for the claim if you have one.
4.      Stick to the clinical facts that support the procedure.  Use the doctor or other provider’s clinical notes. If they aren’t complete, ask for clarity.
5.      Give more detail to the narrative than to the previous submitted such as: “#2 URM decay under existing restoration, lack of remaining tooth structure, full crown necessary.”  Label it ADDITIONAL INFORMATION: “ #2 URM recurrent decay under failing MODL composite; placed 5 years ago, less than 50% of supragingival tooth structure present, cusp fracture, full crown necessary.
6.      Look at the x-rays that you sent. Are they of good diagnostic quality and do they clearly show the whole tooth.  If you sent one periapical, now send the bitewing or the full mouth x-ray if there are missing teeth in the arch. If the x-ray does not give enough visible evidence to the necessity include a labeled intra-oral photo with arrows pointing to the evidence. Submit the periodontal charting to show that there is enough supporting bone. Write this in narrative also.  If you are doing a crown on a tooth that has had endodontic therapy, send the final report letter from the endodontist stating the prognosis status (“favorable”).
7.      Don’t use the verbiage to describe the condition that was used in the denial.  Such as “normal attrition and wear” are used in the denial as the reason for non-coverage then use other words to describe the condition such as “craze line cracks” “fracture lines” “dentin exposure” “cold sensitivity” “pain to loading.”  If an occlusal guard is covered for bruxism then use the word bruxism. The wrong word can trigger a denial.
8.      Let the patient know that you are appealing the denial of his/her claim and it might make a difference if they call the insurance to ask why the denial.  

This is a sample of an appeal letter that resulted in the claim being paid at the maximum allowable; the names of parties involved have been removed. Background on this claim includes the first denial as “not a covered benefit under this plan”, the second appeal denied for “consultant review deems tooth has endo and perio involvement” resulting in the third appeal below:

Dental Insurance Company

Address

Address

Patient: ________ DOB ________ ID ___________

Claim #__________Reference #____

Dear Dental Appeals Consultant,

Per the request of our patient, ______, we are reopening the appeal process for the attached claim with additional documentation.   Because of the reason for denial listed on the last EOB issued _____ and because our patient talked to a representative for_______ and was told the claim “should not have been denied” we are asking you to review all the documents attached to this letter. We have included more information to prove that the treatment was warranted and meets the standard of care necessary to alleviate pain and infection and to restore our patient’s bite to function with a long-term prognosis for success.  Important also is that the treatment is covered benefit under his/her policy.

For clarity I have attached documents to support previous appeals.  Since the root canal therapy on ______ our patient has been pain and infection free.  For _____ months this tooth has not failed so with this in mind, please process this claim for payment.  To deny it for endodontic reasons is absurd as you can see from the attached post-operative report from the endodontist, ______.

Also, for your review is the periodontal charting showing that the bone level around the tooth was good and stable and he has responded to periodontal therapy.  So, to deny the claim for periodontal reasons is also questionable. Please see attached the long-term prognosis for the prosthetic from Dr.________.

Our patient feels a huge injustice because you have denied his claim twice but when he calls you he is told “it should have been paid”.  Please see that this injustice is reversed for our patient, _____ _.

Best regards,

Insurance Coordinator

Dr._______________Practice_________

Attachments________

The next appeal letter also resulted in payment of the highest allowable maximum.

For lack of space I have eliminated the format of the second appeal sample to the body text:

The third appeal is submitted by the request of patient ___________.

We have received your latest denial of the crowns on teeth number 24 and 25 for our patient, _____.  You have seen the evidence but have denied the claim due to “attrition, wear and bruxism.”

The crowns were necessary due to fracture, washed out existing restoration and severe craze or fracture lines which cause the teeth to split or break off when eating.  Because these particular teeth are incisors they have to hold and bite through food for the patient to eat. The patient states that she does not suffer from bruxism and the condition of her teeth does not warrant normal wear and tear.

Our patient______ made a special trip to the office to have additional intra-oral photos taken of her teeth to show the new crowns in place and to also show the condition of the adjoining teeth.  We want you to consider that the teeth that were crowned were in worse shape than the adjoining teeth, which Dr.____ has determined need future treatment.

Since the crowns are standard of care in this situation, I would ask that you review the evidence and give our patient the benefits for these crowns under this policy.

Regards.

I hope this information helps you to get your denied future claims paid.

Dental Billing Tips and News for Pros; Edition #128