A “Sample Letter to Medical Insurance Company Requesting Coverage of Orthodontia” is a letter you send to your insurance provider. You are asking them to cover the cost of braces or other orthodontic treatments. This is common when you or your child needs dental work to straighten teeth.
Dealing with insurance can be tricky. Writing a clear and effective letter is important. We’re here to help simplify the process.
We’ll provide you with sample letters. These examples will guide you. You can adapt them to your specific situation. Get ready to craft your perfect letter!
Sample Letter To Medical Insurance Company Requesting Coverage Of Orthodontia
[Your Name]
[Your Address]
[Your City, State, Zip Code]
[Your Email Address]
[Your Phone Number]
[Date]
[Insurance Company Name]
[Insurance Company Address]
[Insurance Company City, State, Zip Code]
**Subject: Request for Orthodontic Coverage – [Your Policy Number] – [Patient Name]**
Dear [Claims Department/Specific Contact Person, if known],
I am writing to request coverage for orthodontic treatment for [Patient Name], policyholder ID number [Your Policy Number]. [Patient Name] is [Patient Age] years old and a beneficiary under my insurance plan.
[Patient Name] has been evaluated by [Orthodontist’s Name] at [Orthodontist’s Office Name/Address]. The evaluation indicates that orthodontic treatment is medically necessary to correct [briefly describe the dental problem, e.g., severe malocclusion, overbite, crossbite]. This condition is causing [briefly describe the problems it causes, e.g., difficulty chewing, speech impediments, jaw pain].
I have attached a copy of the orthodontist’s report, including diagnostic records and a proposed treatment plan. The treatment plan outlines the expected duration and cost of the orthodontic treatment.
I understand that orthodontic coverage can vary. I would appreciate it if you would review [Patient Name]’s case and determine the extent of coverage available under my policy.
Please send me written confirmation of the coverage determination, including the percentage or amount covered, any applicable deductibles or co-pays, and the pre-approval process, if required.
Thank you for your time and consideration. I look forward to hearing from you soon.
Sincerely,
[Your Signature]
[Your Typed Name]
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How to Write Letter To Medical Insurance Company Requesting Coverage Of Orthodontia
1. Subject Line: Be Perspicacious
The subject line is your initial foray. Make it unambiguous and direct. Instead of a generic “Orthodontia Coverage,” opt for: “Pre-Authorization Request: Orthodontic Treatment for [Patient Name], Policy Number [Policy Number]” This immediately orients the reader to the letter’s purpose and patient details.
2. Salutation: Forge a Formal Connection
Address the letter to a specific individual if possible. Research the claims department or a benefits administrator’s name. If a name is elusive, “Dear Claims Department” is an acceptable alternative. Avoid informal greetings; maintain a professional demeanor. A courteous opening sets a positive tone for your correspondence.
3. Introduction: Concisely State Your Case
In the opening paragraph, articulate the letter’s intent: a request for pre-authorization or coverage for orthodontic treatment. Clearly state the patient’s name, your relationship to the patient (if applicable), and the policy number. For instance: “I am writing to request pre-authorization for orthodontic treatment for my [relationship] [Patient Name], policy number [Policy Number].” Be upfront and avoid ambiguity.
4. Body Paragraph 1: Advocate for Medical Necessity
This is where you expound on the medical necessity of the orthodontic treatment. Enumerate the specific dental issues the patient is experiencing (e.g., malocclusion, overbite, temporomandibular joint dysfunction). Include diagnostic codes if available. Emphasize how these issues impact the patient’s oral health, overall well-being, and daily life (e.g., difficulty chewing, speech impediments, pain). This substantiates your claim beyond mere cosmetic concerns.
- Clearly list the diagnosed dental conditions.
- Explain how these conditions affect the patient’s health.
- Include relevant diagnostic codes if possible.
5. Body Paragraph 2: Bolster with Evidence
Corroborate your claims with supporting documentation. Mention the attachments: a detailed treatment plan from the orthodontist, X-rays, photographs, and any other pertinent records. Explicitly state that these documents substantiate the need for treatment and provide a comprehensive overview of the patient’s condition. Reference the attached documents directly within the paragraph.
- Mention the attached treatment plan, X-rays, and photos.
- Explain how these documents support your request.
- Refer to specific findings within the attachments.
6. Body Paragraph 3: Delve into Policy Specifics
Acknowledge your understanding of the policy’s orthodontic benefits. If the policy stipulates specific limitations or requirements, address them proactively. If you believe the policy language supports your claim, cite the relevant sections. This demonstrates due diligence and strengthens your position. For example, “While I understand the policy has a [limitation], the severity of [patient’s condition] necessitates an exception.”
7. Closing: Reinforce and Request Action
Reiterate your request for coverage and express your anticipation for a favorable response. Provide your contact information (phone number and email address) for easy communication. Close with a formal sign-off, such as “Sincerely” or “Respectfully,” followed by your name. For example: “Thank you for considering this request. I can be reached at [phone number] or [email address]. I look forward to your positive response. Sincerely, [Your Name]”
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Frequently Asked Questions: Orthodontia Coverage
Navigating medical insurance coverage for orthodontia can be complex. This FAQ section provides answers to common questions regarding requesting coverage for orthodontic treatment.
What information should I include in my request letter?
Your letter should include your policy number, patient’s name and date of birth, diagnosis from your orthodontist, treatment plan details, and a request for pre-authorization or coverage determination.
Should I send supporting documentation with my letter?
Yes, include supporting documentation such as a copy of your insurance card, the orthodontist’s treatment plan, X-rays, and any photos that support the medical necessity of the treatment.
How long does it typically take to receive a response from the insurance company?
The response time varies, but it generally takes between 30 to 60 days. Follow up with the insurance company if you do not receive a response within this timeframe.
What if my initial request for coverage is denied?
If your request is denied, review the denial letter carefully to understand the reasons. You have the right to appeal the decision by following the insurance company’s appeals process.
Can my orthodontist assist me with the insurance claim process?
Yes, most orthodontists have staff experienced in handling insurance claims and can assist you in preparing the necessary documentation and communicating with the insurance company.