Treatment Dates —– Prep:___________ Seat:____________
Dear Director of Claims:
It is our understanding that this claim was denied pursuant to your decision that the care given was not dentally necessary.
The explanation of benefits did not give adequate information to establish the accuracy of this decision. Therefore please provide the following information to support the denial of benefits for this treatment.
Please furnish the name and credentials of the insurance representative who reviewed the treatment records. Also, please provide an outline of the specific records reviewed and a description of any records which would be necessary in order to approve the treatment.
Further, we would appreciate copies of any expert dental opinions which have been secured by your company in regards to treatment of this nature and its efficacy so that the treating dentist may respond to applicability to this patient’s condition.
Attn: We are resubmitting the claim with additional information. An approval of this claim will negate the necessity of the paperwork requested. A further denial of this claim will require all the records and information requested within the time specified in the applicable Texas Statutes. A copy of this letter is also being forwarded to the patient and the Texas Insurance Commission for their review.