Additional Information Requested By Insurance Company
City, State ZIP
(or preferably print on letterhead)
Insurance company name
Insurance company address
re: John Doe, claim #1234546779
We received your request for further information regarding this claim. In addition to providing that information, we are including additional narrative to help clarify treatment necessity. Please reprocess this claim with the accompanying information that you requested.
- Copy of original claim
- Copy of your request for further information
- Three periapical x-rays
- Endodontist report
- Additional narrative (on this document)
- Tooth #3 MB cusp is fractured completely off to within 2mm of gingival crest. This is seen better in the new x-ray we are submitting. This tooth has an existing MODL amalgam filling that is 14 years old.
- Tooth #31 recently had root canal treatment completed by an Endodontist. It was diagnosed with pulpal necrosis. Our crown is an initial placement. The x-rays we are sending include a pre-op x-ray showing periapical lesion, and post-op x-ray showing successful completion or RCT. The Endodontist report is also enclosed, showing a favorable prognosis.