Download "Benefit Exception Appeal Letter" Word Document
Appeal Letter Displayed for Your Convenience
Health Symphony Appeal Letter
Your name and address
Address of Claims review department
RE: Name of Insured:
Plan ID #:
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.
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