Appeal Letter for Out-of-Network Provider [Free Sample]

Make sure you have all of the necessary documentation and are prepared to answer questions and fill out any forms the insurance company may request before writing an appeal letter. 

For more details on a typical appeal letter for using an out-of-network provider, see the sample below.

Sample Appeal Letter For Out-Of-Network Provider

January 13, 2022

Virginia Snyder
Blue Cross Blue Shield Insurance Company
9870 Cross Street
New York, NY 10024

Re: Jamie Smith
Medical Coverage –G89078723746 908765678
(Group number/Policy number)

Dear Virginia,

Please accept this letter as an appeal of Blue Cross Blue Shield’s decision to deny coverage for the experimental IBS surgery. 

This procedure has been rejected, according to your notification of refusal of services dated January 10, 2022, because it will be administered by an out-of-network provider.

On October 20, 2021, I was diagnosed with Irritable Bowel Syndrome (IBS), as you are aware. 

Dr. Jonas now believes that an experimental procedure will greatly benefit me. Please notice the following letter from Dr. Jonas, which goes into greater depth about my medical history.

I believe you lacked all of the relevant information when you completed your initial review. I’ve also attached a letter from Dr. Johnson of Maryland Medical Center, who is an out-of-network doctor. 

Dr. Johnson is a renowned specialist in Columbia, Maryland, and one of the best in his industry. His letter goes into greater detail about the procedure that is required. My medical records are also sent, which explain why this additional surgery is required.

Based on the current information, I’m requesting that your company rethink permitting this operation and cover my experimental IBS surgery, as described in Dr. Jonas’ letter. Depending on your approval, the therapy will take place on June 15, 2022.

Please do not hesitate to contact me at 555-410-3488 if you require any additional information. I really anticipate hearing from you on this subject.

Sincerely,

Jamie Smith

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