I have received many calls about claims both dental and medical that are discounted and the office is not in network.  Can they do that, I am asked.

This is a sample letter to use if you are receiving that discount without an explanation

.[~Current Date~]

 Attn: Director of Claims

[~Insurance Policy #1 Carrier~]

[~Insurance Policy #1 Address~]

                Re:          Patient:   [~Patient Name~]

                                Policy:   [~Insurance Policy #1 Number~]

                                Insured: [~Insurance Policy #1 Insured~]

                                Treatment Dates:  [~Admission Date~] - [~Discharge Date~]

                                Amount:  [~Total Charges~]

Dear Director of Claims,

It is our understanding that your company has released full payment on the above referenced claim.  However, it is our position that this claim has still not been reimbursed correctly and that additional benefits are due.

According to the explanation of benefits, benefits for all surgical codes related to this treatment were paid according to the applicable provider contract.

Our review of the provider contract does not reveal any language justifying reductions of this scale.  In order to assess the accuracy of payment, we request a copy of the portion of the fee schedule maximums used in arriving at the payments and an explanation as to how the reimbursement rate is calculated.  It is our position that such maximums should be adjusted based on the usual and customary treatment charges for that specialty and the geographical region where treatment was provided. 

Based on this information, we ask that this claim be reviewed.  We appreciate your prompt attention to this matter.

Sincerely,

Claims Analyst