FREE Sample Health Insurance Appeal Letter
Instructions

Negotiate Your Balance

Download "Sample Health Insurance Appeal Letter" Word Document





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Example Below

Your name and address

Date

Address of Claims review department

RE: Name of Insured:
Plan ID #:
Claim #:

Dear Claims Review Department:

Enclosed are claims that were submitted to you, but have not been paid as of this date.  The charges were rendered on [date of service] and totaled [claim dollar total].  [Health Plan] has denied payment on these charges because [Health Plan] has indicated that these claims were not processed due to their failure to meet the applicable timely claim filing requirement.

Our physician's medical group has stated that they must follow the requirements of their Contract with [Health Plan].  In this case, it appears they did submit their charges to you within the time frame allowed.  We have enclosed the electronic billing submission confirmation record as proof that the charges were billed on time.

This physician provided medically necessary services in good faith.  In consideration of the services rendered, please reconsider your denial and process the submitted claim for payment.  If you have any questions, please contact us or the physician at the numbers listed below.

Sincerely,

[Insured Name]

[Add enclosures, such as statement of medical necessity or medical records if required]

[Provide contact phone numbers]



Before you pay your medical bill, did you appeal first?  Some health plans have a 25% error rate, which means you may be paying for a bill your health plan should had covered.  Submitting an appeal letter is successful in more than 50% of the time.  You could enhance your success rate by using a proven appeal letter.  Please consider purchasing an appeal letter for your denial.


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