How to Handle an Appeal in 3 Steps

Let’s face it, insurance claims get denied. When it happens, it’s important to understand what recourse you have. In most cases, you have the right to appeal the claim and still receive reimbursement for the service. Here’s how:

1) Understand WHY the Claim Was Denied

1. The first step is to review the EOB and determine the exact reason for the denial. All too often the EOB language used is not straightforward. As an example: “procedure is inclusive of another” generally means “not enough documentation was provided.” Members, watch Understanding the Insurance Game
2. If you don’t fully understand the reasoning behind the denial, it can help to call the carrier for more information.
3. For the best chance of succeeding, you must understand the WHY before you can respond with an appeal.

2) Request for Reconsideration

1. Do NOT submit a new claim.
2. Send a written letter for an appeal or reconsideration to the carrier, which should be on your practice letterhead. The letter should clearly state that it is a “Request for Appeal” and should include:
3. The Claim Number of the original case. 
4. Write a brief and clear reason for the appeal.
5. Describe the clinical scenario, why it matches the coding, and why the treatment provided to the patient should be covered.
6. Attach any supporting documentation, including the documentation that was sent with the original claim (often the appeal will be assigned to another reviewer, who may not have access to the original claim). Radiographs, photos, charting, narratives, and relevant clinical notes can add helpful insight to a case.
7. Clearly mark on the original claim that this is an “Appeal” or “Review Request.”
8. State the best way to respond back to you: who, when (days/week and times), how (phone number).
9. Send to the correct address! The appeals department and address can often be different from the original claims department address. Check the EOB to make sure you are sending it to the right location.

3) Follow Up

1. If you do not receive a response within 30 days, you should follow up with the Appeal’s Department to ensure they did, in fact, receive the appeal as well as let them know that you have not received a response.
2. If the claim is denied a second time, you have one more try. At this point, it might be highly useful to have the patient get involved. Most carriers allow you to request a dentist-to-dentist discussion between the treatment provider and the dental consultant. These meetings can be quite helpful if you are well-prepared and handle the conversation professionally.