Just imagine how frustrating the situation is when you treat the patient, bill the insurance company, and then get a denial. And with that, your payments are stuck, and cash flow isn’t smooth.
But the good news is that you can recover much of your revenue. You must be wondering how!
It’s by preparing and/or downloading an appeal letter template, which can be used for any denied or underpaid claim.
Here, we’ll guide you on preparing a professional appeal letter template with a clear format and examples to make your dental billing services smooth.
What Details Do You Need to Prepare an Appeal Letter Template?
An appeal letter template must include the following details:
- Patient details, like name, DOB, insurance member ID, and group number
- Claim number and date of treatment
- Denial reason on the dental EOB
- Clinical notes and narratives to justify the medical necessity of the procedure
- List of supporting documents attached to the letter
- Request for reconsideration of a denied or underpaid claim
- Dentist’s signature and NPI number
How to Prepare an Appeal Letter Template?
Let’s discuss what you need to do to prepare a professional appeal letter template.
Check the Reason for Claim Denials
The first step in managing denied claims and appeals is to check why payers deny claims in the first place. It’s due to reasons like:
- Claim submission after the payer’s timely filing deadline
- Coordination of Benefits issues
- Incorrect CDT coding
- Lack of medical necessity
- Missing or incomplete documentation
- Procedure not covered in the patient’s coverage
- Treatment exceeding frequency limitations in the plan
When you know the denial reason, you can easily prepare the correct appeal letter template. For example, if the payer denies a dental claim due to not proving medical necessity, you can arrange for the required documents. These documents prove that the treatment is important for the patient’s health.
Each issue needs its own template. You can modify the details and content in the letter according to the procedure performed and the relevant information.
Gather all the Supporting Documentation
Once you know the exact reason for claim denial or underpayment, collect all the documents that strengthen your case.
These documents can vary by procedure.
But the most common documents in dental claims include:
- Clinical narratives
- Clinical records
- Intraoral photos
- Narratives
- Periodontal charts
- Prior authorizations
- X-rays
So, check which document your payer expects for the procedure, or what you may add for a strong dental claim.
Review Payer Policy and Guidelines
Check your payer policy rules for their deadlines to submit appeals after you receive the original claim decision in an EOB. Each payer has their own requirements.
For example, Delta Dental requires billers to submit appeals within 180 days of the original decision.
Payers mostly take 30-60 days to review the appeal and make their decision, whether they reimburse or deny the request.
Other requirements may include:
- Submitting a written appeal via letter
- Mentioning if the claim is denied wrongly and needs
- Providing supporting documents to prove medical necessity
You must check your payer’s appeal requirements for your respective state and prepare an appeal letter template accordingly.
Draft a Concise and Clear Appeal Letter
Now, it’s time to draft an appeal letter template. You can prepare the draft:
- Automatically, by using your dental billing software
- Manually, by writing it completely
Now, follow these steps to write the appeal letter in the proper sequence:
- Address the department that reviews your appeals
- Mention the key details like patient information and claim number
- Describe the procedure
- Provide the reason to contest the denial or underpayment, and justify why it should be paid.
- Reference the supporting documents you have attached to the letter
Keep the letter respectful, professional, clinical, specific, and to-the-point. Don’t use emotional tone as you back up your request with facts and reasons to convince the payer.
Attach Supporting Documents
This one might sound obvious.
Scan all the documents in your system or generate automated documents to submit an appeal.
Your payer may require you to attach each document within a certain size limit, like 300KB, and a format like JPG, PNG, or PDF.
Follow the guidelines and attach the documents in the required file size and format to the appeal letter. And, while doing so, make sure that you have attached all the documents in the same order in which you have mentioned them in the appeal.
Submit and Track Appeal
Once you have completed your appeal letter, submit it to the payer. You can either send it to the payer’s email address or submit it directly through the available payer portal.
You may also export a complete PDF package containing the appeal letter and the attachments in the correct order via your software.
When you submit an appeal, the insurer provides you with a tracking number to monitor the status of the appeal. It may be called appeal ID, case number, or grievance number, in the payer’s terminology.
Save the Template
When you have prepared a template, save it in your billing software or make a copy in any word processing tool like Google Docs, MS Word, or Apple Docs. It’s helpful, saving your time in preparing future appeal letters. You can modify the appeal letters according to the need. But the same template can work in most cases, unless these aren’t specific situations.
Examples for an Appeal Letter Template
Let’s check some examples to prepare an appeal letter template.
Standard Appeal Letter Template
It’s the standard template, which you can use for any appeal letter.
[Practice Name]
[Practice Address]
[City, State, ZIP]
[Phone Number]
[Date]
[Insurance Company Name]
[Appeals Department]
[Address]
Re: Appeal for Denied Claim
Dear [Insurance Company] Appeals Department,
We are writing to formally appeal the denial of the above-referenced claim for [Patient Name], treated on [Date of Service] at [Practice Name].
[Paragraph 1: Briefly state what was done and why.]
[Paragraph 2: Address the specific denial reason directly. If it’s a medical necessity, explain the clinical findings. If it’s a coding issue, clarify the correct code and rationale.]
[Paragraph 3: Reference the supporting documentation attached. List everything — X-rays, periodontal charting, clinical notes, referral letters, ADA or AAP guidelines if applicable.]
We respectfully request that this claim be reviewed and reprocessed for payment of $[Amount] for the services provided.
Please do not hesitate to contact our billing department at [Phone Number] if additional information is required.
Sincerely,
[Treating Dentist Name, DDS/DMD]
[NPI Number]
[Practice Name]
Template for Medical Necessity Argument
An insurer can deny a claim for the reason that the patient doesn’t need the procedure. Contest that by building a clinical narrative to explain that the treatment is clinically or medically necessary for the patient.
Your narrative should cover:
- Patient’s symptoms and major complaint
- Clinical findings (bone depths, bleeding on probing, bone loss percentages, etc.)
- Radiographic evidence and details visible on it
- Documented evidence of alternative treatments performed before the said treatment
- Explanation of how the procedure addresses the diagnosed condition
- The risk to the patient’s health if the procedure is missed
- References to clinical guidelines by organisations like the American Dental Association or the American Academy of Periodontology (AAP)
The documents that you attach to it must include only specific documents that directly address the denial reason.
For example, if it’s a:
- Periodontal scaling and root planing denial, attach full periodontal charting with probe depths of 4mm+, bleeding scores, and clinical notes showing failed response to prophylaxis
- Crown denial (wear/fracture), attach pre-op X-rays showing decay or fracture into dentin, photos if available, and a narrative explaining that just a filling isn’t enough to treat the issue
- Bone graft denial, include implant treatment plan, extraction records, and documentation of bone defect severity
Now, based on that, this is a template to appeal for a crown claim with medical necessity.
[Practice Name]
[Practice Address]
[City, State, ZIP]
[Phone Number]
[Date]
[Insurance Company Name]
Appeals Department
[Address]
Re: Medical Necessity Appeal – Crown Denial
Dear Appeals Reviewer,
We are appealing the denial of the crown (D2740) placed on tooth #30. The claim was denied with the statement that a filling would have been sufficient. Based on the patient’s condition, a filling was not an appropriate or long-term solution.
The patient came in with pain while chewing and sensitivity to hot and cold on tooth #30. Upon examination, we found that a large portion of the tooth was broken and weakened. The fracture extended into the inner layer of the tooth (dentin), and the remaining tooth structure was not strong enough to support a filling.
Pre-operative X-rays (attached) clearly show damage extending into the dentin. Clinical photos (attached) show the visible fracture and loss of tooth structure. Because of the size of the break and the weakened cusps, placing a filling would not have protected the tooth from further cracking. A filling would likely have failed and could have led to severe fracture, need for root canal treatment, or possible extraction.
A full-coverage crown was placed to strengthen the tooth, protect it from further damage, and restore proper chewing function. This was the most appropriate treatment to preserve the natural tooth and prevent more extensive and costly procedures.
Attached for review:
- Pre-operative X-rays showing fracture/decay into dentin
- Intraoral photos
- Clinical notes documenting symptoms and diagnosis
- Copy of the original claim and EOB
Based on the documented symptoms, visible fracture, and extent of structural damage to tooth #30, the crown was medically necessary.
We respectfully request reconsideration and prompt reprocessing of this claim.
Sincerely,
[Treating Dentist Name], DDS
[NPI Number]
[Practice Name]
Template for Underpayment
In several cases, payers reimburse less than the contracted fee on a dental claim. This is due to reasons like:
- Applying an incorrect or outdated fee schedule
- Replacing submitted CDT code with a low-cost alternative
- Combining payments for two separate procedures into one
- Miscalculating a patient’s deductible, co-pay, or co-insurance
- Applying an annual maximum that’s not fully exhausted
Based on that, craft an appeal letter template to correct the underpayments. Below is the template:
[Practice Name]
[Practice Address]
[City, State, ZIP]
[Phone Number] | [Fax Number]
[Date]
[Insurance Company Name]
Provider Relations / Appeals Department
[Mailing Address or Fax Number]
Re: Underpayment Appeal — Request for Additional Reimbursement
Dear Provider Relations / Appeals Department,
We are formally appealing the underpayment issued for the above-referenced claim for patient [Full Name], treated at [Practice Name] on [Date of Service]. After carefully reviewing the Explanation of Benefits (EOB) dated [EOB Date], we have determined that the reimbursement received does not reflect the contracted rate outlined in our provider agreement with [Insurance Company Name].
Summary of the Underpayment Issue:
The procedure(s) listed above were submitted under CDT code(s) [Code(s)] and performed as documented in the attached clinical records. Per our current provider participation agreement with [Insurance Company Name], the contracted reimbursement rate for [CDT Code] is $[Contracted Rate]. However, the EOB reflects payment of only $[Amount Paid], resulting in an underpayment of $[Difference].
Applicable Reason for Underpayment:
- If downcoded: The submitted procedure code [Original CDT Code] was replaced on the EOB with [Downgraded CDT Code], reducing reimbursement without clinical justification. The procedure performed meets the clinical criteria for the originally submitted code, as supported by attached clinical notes and radiographs. Request reprocessing under [Original Code].
- If fee schedule error: Payment calculated using outdated fee schedule. Our current agreement, effective [Agreement Date], sets the rate at $[Correct Rate]. Copy attached. Request immediate reprocessing.
- If bundled incorrectly: Procedure codes [Code A] and [Code B] were bundled as one service. These are distinct, separately billable procedures performed on [DOS]. Supporting documentation attached. Request unbundled reimbursement.
- If alternate benefit applied: Payment issued under [Alternate Code] rather than submitted code [Submitted Code]. Attached records support the submitted procedure. Request reimbursement for actual service rendered.
Supporting Documentation Attached:
- Current executed Provider Participation Agreement with fee schedule excerpt
- Original claim form
- EOB dated [EOB Date] showing underpayment
- Clinical notes from date of service
- Radiographs (if applicable)
- Periodontal charting (if applicable)
- ADA CDT code descriptor for [Submitted Code]
Requested Action:
We respectfully request that [Insurance Company Name] review this claim and reprocess it for an additional payment of $[Underpayment Amount], bringing total reimbursement in line with our contracted rate of $[Contracted Rate]. Please issue payment to [Practice Name] at the address above within the timeframe required under [State] insurance regulations.
For additional documentation or discussion, please contact our billing department at [Phone Number] or [Email Address]. We are happy to provide clarification to resolve this promptly.
Sincerely,
[Treating Dentist Name, DDS/DMD]
[NPI Number]
[Practice Name]
[Provider Tax ID]
Template for Timely Filing Appeal
Payers may deny your claim when it deems it a late submission after the timely filing limit expires. However, if you have submitted the appeal before the deadline, you can contest it by writing an appeal letter. This is the appeal letter template for a timely filing appeal:
[Practice Name]
[Practice Address]
[City, State, ZIP]
[Phone Number]
[Date]
[Insurance Company Name]
Appeals Department
[Address]
Re: Timely Filing Appeal
Dear Appeals Department,
We are appealing the denial of the above-referenced claim due to timely filing.
Our records confirm that this claim was submitted within your required filing window. We are providing documentation that verifies timely submission. Please see the attached submission report dated [Submission Date], which includes the electronic timestamp confirming transmission.
The claim was originally submitted on [Submission Date], which falls within your filing limit for the date of service listed above. Based on the attached proof of submission, this denial appears to be in error.
Attached Documentation Includes:
- Clearinghouse submission report with timestamp
- Electronic Remittance Advice (if applicable)
- Practice management system submission screenshot
- Certified mail receipt (if paper claim)
- Copy of original claim
We are providing evidence that this claim was submitted within your required filing window. Please review the attached documentation and reprocess the claim accordingly.
We respectfully request reconsideration and prompt payment.
Sincerely,
[Treating Provider Name]
[NPI Number]
[Practice Name]
Template for Coordination of Benefits Appeal
The payer may deny your claim if you haven’t correctly applied the Coordination of Benefits in dental billing when a patient has subscribed to two insurance plans.
If you have submitted the primary and secondary insurance claims in the correct order, contest it by crafting the following appeal letter template:
[Practice Name]
[Practice Address]
[City, State, ZIP]
[Phone Number]
[Date]
[Insurance Company Name]
Appeals Department
[Address]
Re: Coordination of Benefits Appeal
Dear Appeals Department,
We are appealing the denial of the above-referenced claim due to the Coordination of Benefits.
Based on the patient’s coverage information, [Primary Insurance Name] is the primary carrier and [Secondary Insurance Name] is the secondary carrier. The claim was first submitted to the primary carrier and processed accordingly.
The primary carrier issued payment under EOB dated [Primary EOB Date], which is attached. Per the Coordination of Benefits guidelines, the secondary carrier is responsible for processing the remaining balance according to plan benefits.
We are requesting that you process this claim as the secondary payer and apply benefits as the payer of last resort.
Attached Documentation Includes:
- Primary carrier’s EOB showing payment and patient responsibility
- Completed claim form reflecting primary payment information
- Patient-signed Coordination of Benefits form (if applicable)
- Documentation supporting primary coverage order (birthday rule, employer verification, etc.)
If additional information is required to complete the COB determination, please notify our office promptly.
We respectfully request reconsideration and reprocessing of this claim under the correct Coordination of Benefits guidelines.
Sincerely,
[Treating Provider Name]
[NPI Number]
[Practice Name]
Appeal Template for Claim Denial due to Incorrect Coding
Payer uses CDT code to identify procedures. Using the right CDT code is important for an error-free dental billing and coding process. And if you don’t use it right, the payer denies it.
Below is the appeal letter template to contest a claim denial due to the wrong CDT code.
[Practice Name]
[Practice Address]
[City, State, ZIP]
[Phone Number]
[Date]
[Insurance Company Name]
Appeals Department
[Address]
Re: Appeal for Claim Denial – Incorrect CDT Code
Dear Appeals Reviewer,
We are appealing the denial of the crown placed on tooth #30 due to an incorrect CDT code listed on the original claim. The claim was denied with the explanation that the submitted code did not match the procedure performed.
The procedure performed was a full-coverage crown on tooth #30. The correct CDT code for this treatment is D2740. The original claim had an incorrect or outdated code, which resulted in the denial.
Attached Documents to Support This Appeal:
- Corrected claim form with CDT D2740
- Clinical notes documenting the procedure performed
- Pre-operative X-rays showing tooth #30
- Copy of original Explanation of Benefits (EOB)
We respectfully request that the claim be corrected with the proper CDT code and reprocessed for payment.
Please contact our office at [Phone Number] if additional information is required.
Sincerely,
[Treating Dentist Name], DDS
[NPI Number]
[Practice Name]
Appeal Template for Claim Denial due to Missing Documentation
Here is a template to request reconsideration for a claim denied due to missing documentation.
[Practice Name]
[Practice Address]
[City, State, ZIP]
[Phone Number]
[Date]
[Insurance Company Name]
Appeals Department
[Address]
Re: Appeal for Denied Claim – Missing Documentation
Dear Appeals Reviewer,
We are appealing the denial of the above-referenced claim for Scaling and Root Planing (D4341). The claim was denied due to missing documentation.
Attached Supporting Documentation Includes:
- Clinical notes detailing periodontal examination and pocket depths
- Periodontal charting showing bone loss, bleeding on probing, and inflammation
- Pre-treatment radiographs confirming bone loss in affected quadrants
- Copy of the original claim and Explanation of Benefits (EOB)
The patient presented with significant periodontal disease, including bone loss, bleeding on probing, and inflammation. D4341 was performed to address these issues and prevent further periodontal damage.
We respectfully request that this claim be reviewed with the attached documentation and reprocessed for payment.
Please contact our office at [Phone Number] if additional information is needed.
Sincerely,
[Treating Dentist Name], DDS
[NPI Number]
[Practice Name]
Tips to Speed Up the Appeals Process
Ask Payer Guidelines Before Submission
Before submitting an appeal, if you ask the payer what documents or guidelines it needs for a specific denial reason, it saves a lot of time.
You know in advance what the payer wants and how to send the request that the payer approves. You can check the payer portal, guidelines, or website, or contact their representative directly via call.
Use Policy Language
When you write an appeal letter, directly use the insurer’s language and official rules or policies. It makes your appeal request strong. With that, it’s harder for the insurer to deny your claim as you prove that the claim fully meets payer requirements.
For example, the Liberty Dental Plan of Florida mentions in its provider agreement that the provider should accept the insurer’s maximum amount under the contract as payment in full.
You can use such a clause by payer as well as your fee schedule when you’re appealing for underpayment, referencing that the payer must pay according to the contracted fee.
Follow-up and Escalate
To effectively track the appeal process, ask the payer immediately if it has received your request. Get the confirmation and ask details like tracking number, expected timeframe for the decision, and the name of the reviewer handling your case.
Based on that, if you haven’t received a response to your appeal within the timeframe, it’s time to follow up and escalate the issue.
Contact the payer representative via call or email and document all the details, including the date, time, representative name, and discussion.
If your issue isn’t still resolved, escalate the issue to your state’s Department of Insurance with all the documents. Insurers are bound to follow the state laws. It’s your right to exercise the legal option.
Outsource Appeal Management
Preparing an appeal letter template isn’t an easy task. You need to review all payer policies, check their contracts, and understand their requirements to craft appeals and dispute them. It takes a lot of time and effort, and it’s too much for a practice staff.
And when the staff is overburdened, they are prone to mistakes.
The best solution is to outsource the appeal management to a trusted partner like TransDental. A company that works with all payers knows their policies very well and can easily handle all your denied claims, underpayments, and relevant appeals professionally.
By leveraging automation and expertise from billers, an appeal management company creates and processes well-structured appeals for your claim denials and underpayments. And it is not just processing these appeals, it also tracks them with effective follow-up and escalation by following proper protocols.
The best thing about outsourcing is that you don’t have to pay complete salaries. You pay just a percentage of your claim reimbursements. And your staff is relieved of the burden. They can easily dedicate their time to offering quality care to patients.
Conclusion
Most insurance companies just leave claim denials and appeals, writing them off as revenue loss. But consistent pursuit and denial management can help practices recover the easily collectible revenue.
While preparing appeal letter templates:
- Review the EOB and check the denial or remark code to find the reason
- Follow payer deadlines for submitting appeals and guidelines for compliance
- Attach all the documents and build a strong narrative to justify a claim
- Reference the payer’s rules that prove that a claim submission is valid
- Prepare and save templates
Automate the process in a software to get ready-made templates, which you can customize for any situation. Your software can also automate tracking, follow-ups, and escalations. Or outsource it to a reliable partner who manages the process with expertise and helps you win appeals.
Frequently Asked Questions (FAQs)
How long does a dental claim appeal typically take?
Most first-level internal appeals are resolved within 30 to 60 days of submission. Some carriers are faster, especially if you follow up regularly. Timely filing appeals can sometimes be resolved in under two weeks when documentation is strong.
Can I appeal a claim more than once?
Most carriers allow at least two internal appeal levels before escalating to an external review. If your first appeal is denied, write a second-level appeal with any additional documentation or clinical reasoning you may have left out initially.
What’s the difference between an appeal and a reconsideration request?
A reconsideration is typically an informal request to re-examine a claim, often used when the denial was due to a simple error (wrong code, missing info). An appeal is a formal, documented dispute against a denial decision. Insurers treat them differently, and some carriers require a formal appeal after reconsideration fails.
What if the insurance company doesn’t respond to my appeal?
If you don’t hear back within the carrier’s stated review period, follow up in writing and by phone. Document every contact. If they continue to delay, file a complaint with your state’s Department of Insurance. Carriers are legally obligated to respond to appeals within specific timeframes in most states.
