How do I Write a Letter of Appeal for Medical Claims?

Writing a letter of appeal for medical claims is important because it lets the insurance company know that you don’t disagree with the decisions they have handed down. It also serves as a rebuttal as to why you believe that they should cover the procedure or charges. 

The important thing is to make sure that the letter contains factual information and is writing in a firm tone. While it is important to be pleasant, an appeal letter needs to be strong and let the insurance company know that you mean business. They need to know that you have no intention of backing down regarding the matter at hand.

Appeal Letter Needs To Include

There are a few things that an appeal letter needs to include. Things like the policy number are helpful to allow them to quickly access the account. 

They may also need any group numbers or a claim number that has been assigned to the case. Be sure to reiterate their reason for denying the claim. 

Reason For Their Denial

Use this as a basis for the new letter, start with the reason for their denial and then follow this with a brief history of the illness and the need for the procedure or treatment. 

While this letter may be included in a doctor’s letter that is attached for documentation, it helps to summarize and put things in a quick and readable format.

Was the decision a result of an error on behalf of the insurance company? If you believe this was a mistake, state the correct information that may make all the difference in whether the claim will be approved or denied. It is not uncommon for a coding error to have taken place.

For instance, the insurance company may have you down as receiving one prescription medication when actually it was another one. 

If they are denying coverage because the medication doesn’t fit the realm of your diagnosis then this could be grounds for a denial.

Ask For Reconsideration

Make sure to state why you believe they made the wrong decisions. If you need to go out of network to get the services you need, explain yourself well and attach any documentation necessary. The whole purpose of the letter is to ask for reconsideration.

Before drafting an appeal letter, make sure to have property documentation and be ready to answer questions and fill out any packets the insurance company may ask.