Balance Billed Appeal Letter Free Download

Balance Billed

Download "Balance Billed Appeal Letter" Word Document

Appeal Letter Displayed for your convenience

Health Symphony Appeal Letter

For Balance Bill

Your name and address


Address of Claims review department

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

Dear Claims Review Department:

I am writing to you in regards to a claim submitted by [Medical Provider] for [patient]. The charges were rendered on [Date] and totaled [Claim dollar total]. [Health Plan] has paid [enter payment], but the {version 1: correct payment should have been [enter correct payment]} or {version 2: health plan did not apply the correct discount for being in network.}

Per my policy booklet and information I received from [health plan], the correct payment for this procedure should have been [enter correct payment.] and my responsibility should have been {just a copayment of _____} or {nothing, as the health plan should have paid the claim in full.} Due to the incorrect payment made on this claim, there is a balance remaining, which I am being charged for from my medical provider.

I am not responsible for the balance owed on this bill. Please reconsider this claim and pay the appropriate benefits to the medical provider. If you require additional information or have questions, please contact my medical provider directly at [phone number].

Thank you for your time and consideration.


[Insured’s Name]


By request, additional information from the medical provider

By request, a copy of the policy booklet or name and number of insurance

representative who provided payment information

Billing information of the claim sent originally, including billed date