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Learn how to write a medical insurance claim appeal letter sample. Use our sample medical insurance claim appeal letter as a template for your appeal letter.
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Sample 1 – Medical Insurance Denial Appeal Letter
DATE
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 to Blue Cross Blue Shield’s decision to reject coverage for the colonoscopy procedure.
It is my understanding based on your notification of refusal of services dated DATE, that this procedure has been denied because:
A colonoscopy will not be approved more than once in a twelve month period without the presence of cancerous or precancerous cells.
As you know, I was identified as having Irritable Bowel Syndrome on DATE. Currently Dr. Jonas believes that I will considerably benefit from a second colonoscopy.
Please see the enclosed letter from Dr. Jonas that discusses my medical history in more detail.
I believe that you did not have all the necessary information at the time of your initial review. I have also included with this letter, a follow up letter from Dr. Jonas from OSU Medical Center.
Dr. Jonas is a specialist in Columbus, Ohio and he is one of the top ranking individuals in his field. His letter discusses the procedure that is needed in more detail.
Also included are my medical records, explaining why this additional procedure is necessary.
Based on the current information, I am requesting that your company reconsider allowing this procedure and cover my colonoscopy as Dr. Jonas outlines in his letter.
The treatment is scheduled to take place on DATE, pending your approval. Should you require additional information, please do not hesitate to contact me at 555-710-3456. I look forward to hearing from you regarding this matter.
Sincerely,
Jamie Smith
Sample 2 – Health Insurance denial Appeal Letter
Your Name
Your Address
City, State, Zip Code
DATE
Director of Claims
Name of Insurance Company
Address of Insurance Company
City, State, Zip Code
RE: Policy Number NUMBER appeal for claim denied. Claim number NUMBER
Dear Name of Claims Director,
You denied payment for a procedure that was prescribed by my doctor NAME OF DOCTOR for me after an automobile accident on DATE. The denial stated that the procedure was not medically necessary.
The denial of this claim was not justified and I am appealing it. The explanation you gave for denying the claim was not adequate, since it didn’t include any report of a medical review of my situation, nor did it include the names and credentials of the insurance representative who did review my claim.
I would like copies of any medical opinion that caused the denial of my claim, so I can have the proper medical experts respond with the applicability of this treatment for my condition. Without the physiotherapy treatment, I will not have full use of my legs.
Please review my claim again. Enclosed is a new claim application with the information about the appropriate diagnosis and treatment. I have also enclosed a letter and notes from my physician.
I would like you to cover all the treatment I need to completely recover from the injuries I sustained in the accident.
If you need any further information, I can be reached at 555-123-4567 or at Name@email.com. I hope to get a favorable reply from you within 10 days.
Thank you for your attention to this matter.
Sincerely,
Signature
Printed Name
List of Enclosures
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.