Learn how to write a letter for appealing a health insurance claim denial. Use our sample letter for appealing a health insurance claim denial as a template for your appeal letter.
Sample Letter For Appealing A Health Insurance Claim Denial
May 13, 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 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 April 20, 2022, 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 February 20, 2022.
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 June 1, 2022, pending your approval.
Should you require additional information, please do not hesitate to contact me at 440-710-3456. I look forward to hearing from you regarding this matter.
Frequently Asked Questions (FAQs)
1. What is a health insurance claim appeal?
Answer: A health 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 health insurance claim appeal?
Answer: To file a health 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 health insurance claim appeal?
Answer: The grounds for a health 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 health insurance claim appeal?
Answer: The time frame for filing a health 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 health insurance claim appeal is denied?
Answer: If your health 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.