DentalPayer Essentials · Claim Appeal / Reconsideration

Appeal Successfully Submitted to Payer

Tracking / Appeal Reference: —

Payer Status: Received · Dental Consultant Review · X-ray files received: 0

Reconsideration of Denied Dental Claim

Original claim DPM-CLM-55021934

DeskGate stages quoted facts from RAM into these boxes. The office coordinator reviews and clicks Submit on this page. Autonomous filing is off.

1. Claim and patient

Original Claim Reference

Member / Subscriber ID

Patient Full Name

Date of Birth

2. Services appealed

Procedure Codes (CDT) & Units

Tooth Numbers / Quadrants

3. Denial as stated by the carrier

Denial Reason (quoted from the determination)

4. Appeal narrative

Appeal Narrative (dental necessity)

5. Supporting documents

Supporting Documents (named on the chart)

Radiographs and periodontal charting (PDF upload) *