Dental Insurance Appeal Letter (+ Free Ortho Template)

By Megan Wyrick, Orthodontic Financial Consultant & Co-Founder, The Wyrick Outlook

A dental insurance appeal letter is how an office asks the carrier to look at a denied or short paid claim again, in writing, with proof attached. This one is written for the person in the insurance seat at an orthodontic office, so the template below is built around the claims that actually get denied in ortho: work in progress claims, coordination of benefits, payments held in the middle of treatment.

We coach orthodontic insurance coordinators and run remote insurance billing for ortho practices through twoDO. Appeals are a normal part of that work, and the pattern we see is simple. The offices that get paid are the ones that stop calling and start writing.

What is a dental insurance appeal letter?

A dental insurance appeal letter is a written request asking the carrier to reconsider a claim it denied or paid incorrectly. The American Dental Association’s guide to filing appeals is direct about the format: a proper appeal is a written request, and “a phone call is not acceptable” (ADA Center for Professional Success, How to File an Appeal, 2020). The same guide notes that some plans require the appeal within six months of the original denial, and some allow up to three levels of appeal.

The Wyrick Outlook teaches this process to orthodontic insurance coordinators in Confused 2 Confident™, and our twoDO billing team files them for the ortho practices it bills for. A dental insurance appeal letter that gets paid usually has four things:

• The word “appeal” in the subject line, so it routes to the appeals department instead of the claims queue.
• The claim identifiers, including claim number, patient, subscriber, member ID and the banding date.
• One plain reason the claim should be paid, written as a fact the reviewer can check.
• The proof attached, such as the prior carrier’s EOB, the treatment contract or the chart notes.

Should you call the carrier or send an appeal?

Send the appeal. Calling the carrier again usually puts you back in front of the same entry level representative who processed it the first time. Our Tuesday tip video on dispute forms puts it plainly: when a work in progress claim gets denied, “I immediately send a dispute form or an appeal,” because it goes to “a senior level representative” who “will know exactly what needs to happen.” Every carrier has a dispute or appeal form, and most offices never use it.

Calling still has a place. Use the phone to confirm the claim was received, to get the appeals fax number or address, and to answer a quick question the carrier is waiting on. Use the letter to change a decision.

The 6 ortho denials we see most, and what to attach

Orthodontic claims get denied for different reasons than a crown or a cleaning, because ortho bills in installments across the whole treatment plan. These are the six we see most often, with what to send back.

A note on that table: these come from our own billing work and Megan’s training videos, not from a carrier dataset, and every carrier’s rules differ. Some of these are really resubmissions rather than appeals. If the carrier needs the fee broken into records, initial placement and monthly payments, a corrected claim usually gets paid faster than an argument. The work in progress claim deserves its own guide, and our free work in progress claims guide walks through it.

A timely filing denial we got overturned

Here is one our billing team won recently with Delta. A patient started treatment under Policy A, which paid the first yearly installment and then terminated in the middle of treatment, so the second installment was denied. We worked with the responsible party to update their insurance and submitted a new claim to their active Delta policy. Delta denied it for timely filing, because treatment had started more than a year before the new policy became effective.

Most coordinators would stop there, transfer the balance and collect from the family. We appealed instead. The appeal showed the banding date, the date the new policy became effective, and that the benefit should be prorated from the effective date through the rest of treatment. Delta overturned the timely filing denial and paid the balance on the patient’s account.

What goes in the appeal packet

The appeal packet is the letter plus everything the reviewer needs to say yes without calling you. The ADA guide recommends sending as much supporting documentation as possible, including radiographs, photographs, charting and a narrative, “even if this appears obvious to you.” For orthodontic claims, a strong packet usually includes:

1. The appeal letter, with “APPEAL” in the subject line.
2. A copy of the original claim, with the key fields highlighted.
3. The EOB you are appealing, with the denial code circled.
4. For work in progress claims, the prior carrier’s last EOB showing the lifetime maximum, what it paid and when coverage ended.
5. The treatment contract, when the dispute is about the fee or the length of treatment.

Scan the whole packet into the patient’s chart before it goes out. If the carrier loses it, you resend the same thing the same day instead of rebuilding it from memory.

Dental insurance appeal letter template

Copy this dental insurance appeal letter template onto your letterhead and replace each field in curly brackets. Keep the reason short. Reviewers read a lot of these, and the ones that state one checkable fact get paid faster than the ones that tell the whole story.

{Practice letterhead}
{Date}

{Carrier name}, Appeals Department
{Appeals address or fax number from the EOB}

RE: APPEAL of claim {claim number}
Patient: {patient name}, date of birth {date}
Subscriber: {subscriber name}, member ID {ID}, group {number}
Banding date: {date}. Procedure: {D8080, D8090 or D8670}

Dear Appeals Reviewer,

We are appealing the {denial or reduced payment} of the claim above, processed on {EOB date} with the reason “{denial reason exactly as written on the EOB}”.

We believe this claim should be paid because {one or two sentences of fact, for example: the patient’s coverage with your plan became effective on {date}, and we are requesting payment only for treatment from that date forward}.

Enclosed are {list what you attached}.

Please reconsider this claim and release payment under the patient’s orthodontic benefit. If you need anything else, contact {your name} at {phone} or {email}. If this appeal will be denied, please call us before the decision is final so we can send what is missing.

Sincerely,
{Your name}
Insurance Coordinator, {practice name}

For a work in progress claim, replace the reason paragraph with this version, which follows the process Megan teaches: “This is a work in progress claim. The patient was banded on {date} under prior coverage with {prior carrier}, which ended on {date} after paying {amount} of a {amount} lifetime maximum. Coverage with your plan became effective on {date}. We are requesting payment for treatment from that date forward.” Mark the claim form the same way, with “work in progress” and the effective date in box 35, and mail it with the prior carrier’s EOB.

When the same denials keep coming back

An appeal letter fixes one claim. When the same denials keep coming back, the problem sits upstream, usually in verification or in how claims get built in the first place. Coordinators tell us this directly. Claims denied or processed incorrectly ranked third among the struggles 325 coordinators named before starting our insurance course, behind work in progress claims and coordination of benefits (TWO course intake survey, 2021 to 2026). One wrote that her claims kept “being denied due to missing info when it is clearly on my claim.”

Most of the denials in the table above can be prevented at the front end. Verifying the right primary carrier, the age limit and whether the plan pays at UCR stops several of them before treatment starts, and our orthodontic insurance verification form covers each of those questions. Building the claim the way each carrier wants it stops most of the rest.

That is what Confused 2 Confident, our orthodontic insurance billing training, is for. It covers verification, coordination of benefits, work in progress claims and how to handle rejected or underpaid claims and appeal them, for $998, and one registration covers your whole office. If you already have a stack of aged denials and no time to work them, our 1-Time Clean Up is a one time project where the twoDO team works the backlog for you.

Track every appeal until it pays

An appeal that nobody follows up on is a claim that ages anyway. The rule we teach for claims applies here too: “we never want to have a claim outstanding for more than 30 days.” Check the carrier’s portal or call a week or two after the appeal goes out to confirm they have it, then follow up every one to two weeks until it pays. Log the date sent, the method and the next follow up date on the patient’s account, so anyone on the team can pick it up.

Frequently asked questions

How long do you have to appeal a dental insurance denial?

It depends on the plan, so check the EOB and the plan documents. The ADA notes that some plans require appeals within six months of the original denial.

Can I appeal a dental claim over the phone?

No. A phone call can confirm details or get the appeals address, but the ADA’s guidance is that a proper appeal is a written request. Send the letter and keep a copy in the chart.

What is the difference between a corrected claim and an appeal?

A corrected claim fixes something your office got wrong, such as a missing date, the wrong code or a fee that was not broken out the way the carrier requires. An appeal asks the carrier to change a decision when the claim was right and the carrier processed it wrong. If you are not sure which you need, read the denial reason on the EOB. A request for information or a different format usually means a corrected claim. A denial of coverage you can prove usually means an appeal. Sending an appeal when the carrier only needed a corrected claim adds weeks, so check first.

Should a patient write their own dental insurance appeal letter?

Patients can appeal on their own behalf, and sometimes a letter from the subscriber helps. For orthodontic claims, the office usually has the claim history, the prior EOBs and the treatment contract, so the office is better placed to write it. Our coordination of benefits guide helps when the question is which plan should have paid.

Megan Wyrick is a co-founder of The Wyrick Outlook, where she helps orthodontic practices run clean revenue cycles and collect what they have already earned. With 15 or more years in orthodontic financials, insurance and collections, she has worked nearly every seat on the money side of an ortho office, and she teaches appeals inside Confused 2 Confident. Megan and her sister B have partnered with more than 450 practices. More about Megan.