Benefit Exception Non Licensed Agency Appeal Letter Free Download


Benefit Exception Non Licensed Agency

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Health Symphony Appeal Letter

Benefit Exception

Your name and address

Date

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 denied payment for this procedure, stating that the Home Health Agency was not licensed.

Option 1: The State of Kentucky does not require a Home Health Agency to be a licensed provider. The current condition requires that the services of a Home Health Agency be obtained. Home Health Agency visits are a covered expense under my plan. I am requesting that you reconsider your denial for this service and immediately authorize payment. I am including with this appeal letter, documentation that supports this statement.

Option 2: The services received from this Home Health Agency were necessary and I am requesting that you reconsider your denial and allow payment on this claim. We searched for a licensed agency in the area who could provide the type of services required. I exhausted a great deal of effort in this search, but was not successful.

Option 3: The services received from this Home Health Agency were necessary and I am requesting that you reconsider your denial and allow payment on this claim. In order for me to fully utilize the benefits available to me by my health plan, I am requesting that you allow this service by exchanging them from an under-used or non-applicable benefit in my plan. This has been used and documented by other health plans to serve the needs of their members and I am asking that you extend the same courtesy to me.

As a member of [health plan] I am requesting your reconsideration of this denial and extend the coverage for me. If there is any additional information I could provide to you that would expedite this matter, please feel free to contact me. Thank you for your time and assistance in this matter.

Sincerely,

[Insured Name]

Enclosures:
A referral from your physician to use this agency
An article explaining the benefits of coverage and how much can be saved
A list of benefits you would be willing to give up in exchange for additional benefits
An explanation of the costs per treatment and possible cost savings