Third-Party Payer Complaint Form

This form enables dental offices to provide the ADA with information on the challenges they experience with third-party payers, which supports tracking member concerns and facilitates the Council on Dental Benefit Programs’ discussions with benefit plan providers. Please complete a separate form for each third-party payer incident you wish to report.

Please do not include any personally identifiable health information on this form, and do not send copies of claim forms or Explanation of Benefits (EOB) statements.

*Indicates required field.

Member Information

*First Name:		Date:

*Last Name:

*Third-Party Payer:

*Practice State

*Participating in Network:

Yes
No

Claim Information Check all that apply

Original

Resubmitted Claim

Appealed Claim

Complaint - Issue(s) Check all that apply

Bundling (combing distinct procedures that results in a reduced benefit)	Interference with the doctor-patient relationship
Coordination of benefits	Lost claims, x-rays or other documentation by carrier
Delayed payment	No direct pay to non-participating provider
Denial of claim or pre-authorization	Utilization Review (a system to evaluate procedure utilization frequency/plan abuse)
Denial of payment after pre-authorization	Withholding payment for same patient
Downcoding (changed code to a less complex or lower cost procedure)	Withholding any future payments to provider
Eligilbilty of patient	Extensive or additional documentation requested
EOB language	Review by non-Dentist
	Procedure Codes:

Explanation of Benefits (EOB) Check text that matches your EOB language
Medical Necessity
Appropriate Care
Procedure included in another procedure
Or write text as it appears:

Who did you contact and how? check all that apply

	Company Representative	Dental Consultant	Other
Correspondence
Phone Conversations