Letter To Insurance Company For Claim: Medical claim letter is required when a health care provider is considered out of network with the insurer and does not provide any medical procedure services to the patient in question. In these instances, patients, or their representatives, must submit the claim themselves using a Medical Claim Letter. The letter includes all of the relevant information that an insurer is likely to need in order to process a claim.
Looking for tips on how to write a health claim letter? Here are some examples below.
#1. Sample Letter To Licensing And Certification
[YOUR NAME]
[YOUR ADDRESS]
[LICENSING & CERTIFICATION DISTRICT OFFICE ADMINISTRATOR]
[LICENSING & CERTIFICATION DISTRICT OFFICE]
[DISTRICT OFFICE ADDRESS]
RE: [NAME OF HOSPITAL]’s failure to comply with the financial assistance guidelines of AB 774
Dear District Administrator [NAME OF ADMINISTRATOR],
I received care at [NAME OF HOSPITAL] on [DATES OF SERVICE]. The hospital is demanding payment on this bill, [and/or] my bill has been sent to collections, [and/or] I am being sued for collection of this bill, [and/or] I was forced to pay more than I owe.
My income does not exceed 350% of the federal poverty level and I am uninsured [or] my annual out-of-pocket medical costs exceed10% of my income. According to the California Health & Safety Code § 127405, I should be eligible for charity care or a discount on my charges with an extended payment plan.[Select all the circumstances which apply]
- I was not given written notice regarding the hospital’s charity care or discount payment policy while in the hospital, or when I was billed, [and/or] in the language I speak.
- I applied for financial assistance, but the hospital refused to accept my application.
- I applied for financial assistance, but the hospital did not process my application and make a final determination.
- The hospital refused to give me an application for charity care or a discount payment program.
- I was not permitted to set up a reasonable payment plan.
- My application for financial assistance was improperly denied. [Explain circumstances]
Please review [NAME OF HOSPITAL]’s failure to comply with the requirements of AB 774. I ask that you do everything in your power to force the hospital to comply as hospitals are required to follow this statute in order to stay licensed.
I authorize Licensing and Certification to disclose my name to the hospital solely for the purposes of this investigation. Please require that the hospital reduce or forgive my bill according to their policy [and/or] reimburse me with interest the amounts I already paid in excess.
Please let me know when you will respond to this complaint and how it is ultimately resolved. Thank you for your time.
Sincerely,
[YOUR NAME]
#2. Sample Letter To Hospital
[YOUR NAME]
[YOUR ADDRESS][HOSPITAL NAME]
[HOSPITAL ADDRESS]
Dear [HOSPITAL NAME],
I received medical care at your hospital on [DATE]. I am now receiving bills from the hospital, [and/or] receiving notices from one or more collections agencies, [and/or] being sued for collection of this bill by [INSERT NAME OF AGENCY SUING].
My family income is no more than 350% of the federal poverty level and I am uninsured [or] my out-of-pocket health care costs exceed 10% of my income. According to AB 774 (California Health & Safety Code §127400 et seq), I should be eligible for charity care or a discount payment program offered by the hospital.
[Select all the circumstances which apply]
- I was not given written notice regarding the hospital’s charity care or discount payment policy while in the hospital, or when I was billed, [and/or] in the language I speak.
- The hospital refused to give me an application for charity care or a discount payment program.
- I was not permitted to set up a reasonable payment plan.
- I applied for financial assistance, but the hospital refused to accept my application.
- I applied for financial assistance, but the hospital did not process my application and make a final determination.
- My application for financial assistance was improperly denied. [Explain circumstances]
Until this matter is resolved, any collection activity against me is unlawful. If I am not offered payment assistance as required by law, I will file a complaint with the Department of Health Services or seek other remedy as permitted by the laws of this state. I also ask that you assist me in repairing any damage that may have been done to my credit. Please notify me immediately as to how you intend to resolve this.
Sincerely,
[YOUR NAME]
Cc: [OTHER ENTITIES ATTEMPTING TO COLLECT ON THE BILL]
#3. Sample Letter To Collection Agency
[YOUR NAME]
[YOUR ADDRESS]
[COLLECTION AGENCY NAME]
[COLLECTION AGENCY ADDRESS]
Re: Request for Suspension of Collection Pending Determination of Eligibility for Hospital Financial Assistance
Dear [COLLECTION AGENCY NAME],
My hospital bill from [HOSPITAL NAME] has been sent to you for collection. I believe that I should have been offered and granted financial assistance for the medical services that I received at [HOSPITAL NAME] on [INSERT DATE(S) OF SERVICES].
California has a new Hospital Fair Pricing Policies law that requires hospitals to have written financial policies and notify their patients of these policies. CA Health & Safety Code § 127400 et seq. According to the law “Uninsured patients or patients with high medical costs who are at or below 350 percent of the federal poverty level . . . shall be eligible to apply for participation under each hospital’s charity care policy or discount payment policy.” CA Health & Safety Code § 127405(a).
[Select the circumstances that apply]
- The hospital wrongfully denied me financial assistance according to the requirements of CA Health & Safety Code § 127400 et seq and I am appealing this decision [or] filing a complaint with the Department of Health Services.
- I am uninsured and the hospital did not inform me that I could apply for financial assistance or seek coverage from government program as required by CA Health & Safety Code § 127410(a) and § 127420(b). I am now trying to do so.
- I have applied for financial assistance and am waiting for a decision from the hospital. CA Health & Safety Code § 127425(e) requires that you wait to collect on this bill.
- According to CA Health & Safety Code § 127425(d), you may not report me to a credit reporting agency or commence a civil action against me for 150 days after I was initially billed.
If you continue to try to collect on this bill before a determination of financial assistance is made on my account, you may be in violation of the Rosenthal Fair Debt Collection Practices Act and the federal Fair Debt Collection Practices Act. CA Civil Code § 1788 et seq. and 15 U.S.C. § 1692 et seq.
I am asking that you cease collection on this bill until [HOSPITAL NAME] makes a decision regarding my financial assistance application.
Sincerely,
[YOUR NAME]
CC: [HOSPITAL NAME] (Send a copy to the hospital)
#4. Sample Letter Of Medical Necessity
Medical Necessity Letter outlines the information a payer may request. As some payers may require that the prescriber documents a patient’s medical necessity for treatment to get insurance coverage for a pharmaceutical product.
[Name of Pharmacy Director/Payer Contact]
[Contact Title]
[Name of Health Insurance Company]
[Address]
[City, State, ZIP Code]
RE: Coverage for [Product Name]
Patient: [Patient Name]
Date of Birth: [Date]
Diagnosis: [Diagnosis], [ICD-10-CM]
Group/Policy Number: [Number]
Policyholder: [Policyholder Name]
Dear [Pharmacy Director/Payer Contact Name],
I am writing on behalf of my patient, [Patient Name], to document the medical necessity to treat their [Diagnosis] with [Product Name].
This letter serves to document my patient’s medical history and diagnosis and to summarize my treatment rationale. Please refer to the [List any Enclosures] enclosed with this letter.
Summary of Patient’s Medical History and Diagnosis
[Patient Name] is [Age] years old and was initially diagnosed with [Diagnosis] [ICD-10-CM] on [Date]. [Patient Name] has been in my care since [Date].
[Provide a discussion of the patient’s clinical history, current symptoms and condition, any potential contraindications, and any relevant laboratory test results, highlighting the factors leading you to recommend use of the product]
Rationale for Treatment
[Include your clinical rationale and reasons for prescribing the product]
In summary, [Product Name] is medically necessary and reasonable to treat [Patient Name’s] [Diagnosis], and I ask you to please consider coverage of [Product Name] on [Patient Name’s] behalf. Please refer to the enclosed supporting documents for further details, and do not hesitate to call me at [Phone Number] if you have any questions or if you require additional information.
Thank you for your attention to this matter.
Sincerely,
[Prescribing Physician Name and Credentials]
[NPI Number]
Enclosures: [List any Enclosures, such as: Prescribing Information, Medication Guide, and Clinical Notes and Records]