Benefit Exception Appeal Letter Free Download


Benefit Exception

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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 it is not a covered benefit under my plan.

Option 1: The current medical condition requires that this medical treatment be allowed so that I may fully recover. This medical treatment should be a covered expense by my plan. I am requesting that you reconsider your denial and immediately authorize it to be paid. My Physician is 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 pay for this medical treatment. In order for me to fully utilize the benefits available to me by my health plan, I am requesting that you allow this treatment by exchanging them from an under-used or non-applicable benefit in my plan. This has been accepted 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