Writing an appeal letter for claims denial can be daunting especially when it has to do with health related issues. It is important to note that some insurance companies may reject claims for certain health services. You need to know that you have the option to appeal these denials.
If you have had treatment that the claims was subsequently denied and you are looking for how to write an appeal letter or reconsideration letter to an insurance company, you are on the right page. In this post are samples of insurance denial appeal letter templates to guide you on where to start from.
Choose any denial appeal letter sample suitable for your situation and make the appropriate modification needed. Good luck!
Dear [Name of contact person at insurance company],
Please accept this letter as [patient’s name] appeal to [insurance company name] decision to deny coverage for [state the name of the specific procedure denied]. It is my understanding based on your letter of denial dated [insert date] that this procedure has been denied because: [quote the specific reason for the denial stated in denial letter]As you know, [patient’s name] was diagnosed with [disease] on [date]. Currently Dr. [name] believes that [patient’s name] will significantly benefit from [state procedure name]. Please see the enclosed letter from Dr. [name] that discusses [patient’s name] medical history in more detail.
[Patient’s name] believes that you did not have all the necessary information at the time of your initial review. [Patient’s name] has also included with this letter, a letter from Dr. [name] from [name of treating facility]. Dr. [name] is a specialist in [name of specialty]. [His/Her] letter discusses the procedure in more detail. Also included are medical records, and several journal articles explaining the procedure and the results.
Based on this information, [patient’s name] is asking that you reconsider your previous decision and allow coverage for the procedure Dr. [name] outlines in his letter. The treatment is scheduled to begin on [date]. Should you require additional information, please do not hesitate to contact [patient’s name] at [phone number]. [patient’s name] will look forward to hearing from you in the near future.
Sincerely,
[Your name]
[Date]
[Insurance Company Name]
[Appeals and Grievances Department]
[123 Apple Street]
[Anytown, VA 12345]
RE: [Your Name]
[Member ID #]
[Reference # on Explanation of Benefits]
[Your Date of Birth]
Dear [Insurance Company Name],
My name is [patient] and I am a policyholder of [insurance company]. I wish to file an appeal concerning [insurance company name’s] denial of a claim for [procedure name]. I received an Explanation of Benefits dated [provide date] stating [provide denial reason directly from letter].
As is evident from my previous medical claims, I was diagnosed with [migraine/chronic migraine] on [date]. Unfortunately, there is significant impact to my daily life as evidenced by [explain symptoms]. I am currently under the care of [doctor name] at [facility name]. In the Letter of Medical Necessity I attached, he/she outlined why this [procedure] is clinically beneficial for me. He/she states, “[provide statement from letter that supports treatment].” Please consult his/her letter for more significant medical history. As well, I have included supplemental materials regarding the nature of the procedure and some additional details about the procedure itself and the efficacy of it for my condition.
Please thoroughly review the provided documents and reconsider the previous adverse decision to allow coverage of [procedure], as this treatment was necessary to my health. Should there be additional supporting information you require to render a positive decision, please do not hesitate to contact me at [your phone number] or my physician at [doctor’s phone number]. Thank you for your attention in this matter. Your prompt consideration to this appeal is appreciated.
Sincerely,
[Your Name]
[Your Address]
Enclosures:
CC: [Name of Treating Doctor]
ATTN: Prior Authorizations/Appeals
Re: Coverage of [Product Name/generic name/dosage form]
[Patient First Name]
[Patient Last Name]
[Policy Number]
[Group Number]
[Patient Date of Birth]
Diagnosis: [ICD‐10‐CM Code] [Diagnosis]
Claim or Reference Number: [Claim or Reference Number]
Submission Date: [Submission Date]
Denial Date: [Denial Date]
To whom it may concern:
I am writing to request a review of a denial for coverage of [Product Name] for [Patient Name]. Your company has denied this claim for the following reasons: [Insert reasons]
[Patient Name]’s medical history and course of treatment are as follows:
[Describe the patient’s history, including diagnostic test results, previous and current treatment regimens, and their outcomes]
Based on the information provided above, the use of [Product Name] is medically appropriate and necessary for [Patient Name]. I have enclosed a copy of the Full Prescribing Information for [Product Name].
I respectfully request that you review the additional documentation provided and consider overturning your coverage decision regarding [ Product Name] for [Patient Name]. Thank you for your prompt attention to this matter. I look forward to your reconsideration. If I can provide any additional information, please contact me.
Regards,
[Physician Name]
[NPI Number]
[Phone Number]
[Fax Number]
[Suggested enclosures: Original prior authorization form, denial letter/explanation of benefits (EOB), Full
Prescribing Information, medical literature regarding the use of [Product Name] for [ICD‐10‐CM Code] 089-0192-PM 10/19
[Diagnosis], relevant clinical documentation (eg, history and physical, progress notes describing treatment history and outcomes), other relevant supporting documents]
[Date]
[Name]
[Insurance Company Name]
[Address]
[City, State ZIP]
Re: [Patient’s Name]
[Type of Coverage]
[Group number/Policy number]
Dear [Name of contact person at insurance company],
Please accept this letter as my appeal to [insurance company name] decision to deny coverage for [state the name of the specific procedure denied]. It is my understanding based on your letter of denial dated [insert date] that this procedure has been denied because: [quote the specific reason for the denial stated in denial letter]
I have been a member of your [state name of PPO, HMO, etc.] since [date]. During that time I have participated within the network of physicians listed by the plan. However, my primary care physician, Dr. [name] believes that the best care for me at this time would be [state procedure name]. At this time there is not a physician within the network who has extensive knowledge of this procedure. Dr. [name of primary care physician], a plan provider, has recommended that I have the procedure done outside the network by Dr. [name of specialist] at [name of treating facility].
I have enclosed a letter from Dr. [name of primary care physician] explaining why he recommends [name of procedure]. I have also enclosed a letter from Dr. [name of specialist] explaining the procedure in detail, his qualifications and experience, and several articles that discuss the procedure.
Based on this information, I am asking that you reconsider your previous decision and allow me to go out of network to Dr. [name] for [name of specific procedure]. The procedure is scheduled to begin on [date]. Should you require additional information, please do not hesitate to contact me at [phone number]. I look forward to hearing from you in the near future.
Sincerely,
[Your name]