A medical insurance appeal letter is necessary because it informs the insurance company that you do disagree with their decisions. It also serves as a counter-argument to why you believe the treatment or expenses should be covered.
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The most crucial thing is to make sure the letter is factually accurate and written in a decisive tone. While it’s crucial to be courteous, an appeal letter should be firm and show the insurance company that you’re serious about your case.
They must understand that you have no intention of backing down on the issue at hand. There are a few items that must be included in an appeal letter.
The policy number, for example, is useful in allowing them to immediately access the account. They may also require any group numbers or claim numbers associated with the case.
Reiterate Their Reason For Denying The Claim
Make careful to state why they are denying the claim. Start with the reason for their refusal, then move on to a brief history of the ailment and the need for the procedure or therapy.
While this letter may be included in a doctor’s letter that is attached for documentation, it aids in the summary and organization of information.
Was the decision made as a result of a mistake on the insurance company’s part? If you believe there was an error, state the proper information, which could be the difference between the claim being approved or refused. It’s not unheard of for there to be a code error.
For example, your insurance company may have you listed as having received one prescription drug when you actually received another. It’s possible that they’re denying coverage because the medicine doesn’t fit within the scope of your diagnosis.
State Why You Believe They Made The Wrong Decisions
Make sure to explain why you believe they made the wrong decisions. If you need to go outside of the network to receive the services you need, explain why and include any supporting evidence.
The letter’s sole goal is to request reconsideration. Make sure you have proper documents and are prepared to answer questions and fill out any packets the insurance company may need before writing an appeal letter. For additional details on a common medical insurance appeal letter, see the sample below.
Sample Medical Insurance Appeal letter
February 9, 2022
Blue Cross Blue Shield Insurance Company
9870 Cross Street
New York, NY 10024
Re: Jamie Smith
Medical Coverage –G89078723746 908765678
(Group number/Policy number)
Please accept this letter as an appeal against Blue Cross Blue Shield’s refusal to cover the colonoscopy surgery.
Based on your rejection of services notification dated January 31, 2022, I believe this procedure has been rejected because:
Without the evidence of malignant or precancerous cells, a colonoscopy will not be approved more than once every twelve months. On January 20, 2022, I was diagnosed with Irritable Bowel Syndrome, as you already aware.
Dr. Jonas now believes that a second colonoscopy would be beneficial to 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 included a follow-up letter from Dr. Jonas of OSU Medical Center with this letter. Dr. Jonas is a renowned specialist in Columbus, Ohio, and one of the best in his area.
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 am requesting that your company rethink permitting this operation and cover my colonoscopy as described in Dr. Jonas’ letter.
Depending on your approval, the therapy will take place on March 9, 2022. Please do not hesitate to contact me at 740-710-3456 if you require any additional information. I really anticipate hearing from you on this subject.
Frequently Asked Questions (FAQs)
1. What is a medical insurance claim appeal?
Answer: A medical insurance claim appeal is a request made by a policyholder to their insurance company to review and potentially overturn a denied claim for medical treatment or services.
2. How do I file a medical insurance claim appeal?
Answer: To file a medical insurance claim appeal, you should first gather all relevant documentation, such as medical records and bills, and then contact your insurance company to request an appeal. You may be required to submit a written request, along with the supporting documentation.
3. What are the grounds for a medical insurance claim appeal?
Answer: The grounds for a medical insurance claim appeal may vary depending on the insurance company and the specific circumstances of the claim. However, common grounds include new information or evidence, errors or inconsistencies in the initial claim, or a determination that the treatment or service is medically necessary.
4. How long do I have to file a medical insurance claim appeal?
Answer: The time frame for filing a medical insurance claim appeal may vary depending on the insurance company and state laws. It is important to check your insurance policy or contact the insurance company for specific information about the appeal process and deadlines.
5. What happens if my medical insurance claim appeal is denied?
Answer: If your medical insurance claim appeal is denied, you may have additional options for appealing the decision. This could include asking for an external review, appealing to the state insurance commissioner, or potentially taking legal action.