Benefit Exception Therapy Appeal Letter Free Download


Benefit Exception Therapy

Download "Benefit Exception Therapy Appeal Letter" Word Document



Appeal Letter Displayed for Your Convenience


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 medical procedure, stating that only [number] of visits are allowed under my plan, and therefore, additional visits for physical therapy are not covered.

Option 1: The current medical condition requires that additional physical therapy sessions be allowed so that I may fully recover to a pre-accident or incident level. This physical therapy should be a covered expense by my plan. I am requesting that you reconsider your denial for these additional sessions and immediately authorize them. My Physical Therapist and Referring Physician are prepared to provide you with documentation to satisfy your requirements of “medical necessity”.

Option 2: Due to the medically necessary treatment I require, I am requesting that you reconsider your denial to not allow at least [number] of sessions for physical therapy. In order for me to fully utilize the benefits available to me by my health plan, I am requesting that you allow the additional sessions 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 statement of medical necessity
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