You can open the Reconsideration Dental Insurance Appeal Letter Template in multiple formats, including PDF, Word, and Google Docs.
Reconsideration Dental Insurance Appeal Letter Template Printable | Editable FormSample
Examples
[Name of the Insurance Company]
[Company’s Address]
[City, State, Zip Code]
[Your Name]
[Your Address]
[City, State, Zip Code]
[Your Phone Number]
[Your Email]
Request for Reconsideration of Dental Claim #[Claim Number]
[Date]
I am writing to formally request a reconsideration of the claim #[Claim Number] that was denied on [Denial Date]. After reviewing the denial letter, I believe there may be grounds for an appeal based on the following information.
The original claim was submitted for [Specify dental procedure or service], which was performed on [Date of Service]. The procedure was deemed necessary by my dentist, [Dentist’s Name], as outlined in the attached documentation.
The claim was denied due to [Specify reason for denial, e.g., “services not covered under the policy,” “lack of pre-authorization,” etc.]. However, [Explain why the denial may be incorrect and provide supporting arguments or evidence].
I have included the following documentation to support my request for reconsideration:
– Copy of the claim submitted
– Denial letter from the insurance company
– Treatment plan and explanation from my dentist
– Any additional supporting documents (e.g., x-rays, receipts, etc.)
I kindly request that you review my case again and reconsider the decision regarding claim #[Claim Number]. I believe the additional information provided will clarify the necessity of the procedure and its coverage under my dental insurance plan.
[Your Signature (if sending a hard copy)]
[Your Name]
[Name of the Insurance Company]
[Company’s Address]
[City, State, Zip Code]
[Your Name]
[Your Address]
[City, State, Zip Code]
[Your Phone Number]
[Your Email]
Appeal for Reconsideration of Dental Claim #[Claim Number]
[Date]
This letter is to formally appeal the denial of claim #[Claim Number] submitted for [Specify dental procedure or service]. The denial was received on [Denial Date], and I am providing further details and justification for my appeal.
The initial claim involved [Describe the procedure and its necessity, citing your dentist’s recommendations]. The procedure was essential for my oral health, and I trust that it falls within the coverage of my dental plan.
As per the denial, the reason noted was [Specify reason for denial]. However, I would like to contest this denial because [Provide your argument and evidence].
Attached you will find necessary documentation supporting my appeal, including:
– A copy of the original claim
– The letter of denial
– Correspondence from my dental provider
– Relevant medical records or statements
– Any additional documentation as needed
I hope you will reconsider the decision on claim #[Claim Number]. I believe the provided information will demonstrate that the dental service received is covered under my policy. Prompt attention to this matter is greatly appreciated.
[Your Signature (if sending a hard copy)]
[Your Name]
Format
Please complete the form below to create the Reconsideration Dental Insurance Appeal Letter Template. All fields must be filled out to ensure a comprehensive and well-structured appeal. We provide examples to guide you through each step. Reconsideration Dental Insurance Appeal Letter Template 1. Patient Information 2. Insurance Company Information 3. Appeal Details 4. Reason for Appeal 5. Supporting Documentation 6. Previous Decision Details 7. Requested Resolution 8. Signature and Acknowledgment 9. Declaration and Signatures
PDF
WORD
Google Docs
Reconsideration Dental Insurance Appeal Letter Template Printable | Editable FormPrintable
