INSURANCE CLAIM NARRATIVE - Roz Fulmer
(Name of Provider) D.D.S./D.M.D.
Dear Dental Claims Consultant:
This request for reimbursement is for ___________________________________________________,
SS#-ID# _______________________________ Date of Service: ____________________
Please excuse the informality of this letter; it is an invaluable aid to my office in the administration of dental claims reimbursement. I realize the difficulty in determining when treatment is necessary if only the x-rays are provided. The intent of this letter is to provide supplemental information to aid in your review of this claim for dental benefits for my patient.
Tooth Number(s) #31
Cast restorations are not being placed because of corrosion, attrition or abrasion, restoration of occlusion, alteration of vertical dimension, esthetics or splinting.
____ Initial Placement
_X__ Existing large failing restoration
____ Undermined and weakened cusps or incisal edges
_X__ Decay present
____ Preserve of vertical/horizontal enamel fractures on buccal/lingual surfaces not visible on the
x-rays and the tooth is biting sensitive (Cracked Tooth Syndrome)
__X_ Replacement of existing cast restoration over 5 years old that have opened and decayed
margins.
____ Initial placement of abutment cast restorations for a fixed bridge
__X_ Fractured distal / buccal cusps.
____ Placement of cast restorations on teeth to be / previously treated root canals
__X_ Build-up required; insufficient tooth structure remained circumferentially for retention
____ Other _______________________________________________________________________
I trust this has been helpful in determining benefits for this patient. I thank you in advance for your help in getting this claim processed for reimbursement. If you should feel the need to call me personally for additional information, please do so. My number is (555) 555-5555.
Sincerely,
Charles I Feelgood D.D.S.
Enclosures: __________ X-rays for tooth number _______ Claim form ______ Letter ______ Other
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.