Download "Reversing a Benefit Penalty Appeal Letter" Word Document
Appeal Letter Displayed for Your Convenience
Health Symphony Appeal Letter
For Reversing a Benefit Penalty
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 considered the charges and made a payment of [paid total], but this was after a benefit penalty of [amount of penalty] was deducted from the payment.
[Patient] was involved in a serious accident and transported to the nearest emergency facility. I was unaware of a required pre-authorization procedure and under the circumstances, didn't think to investigate the policy booklet for pre-authorizing inpatient hospital stays.
The policy booklet does state that the pre-authorization hotline must be called within [days] of the patient's admittance to the hospital for emergency situations. However, I did provide both the hospital and attending physician my insurance information upon admittance and neither one of them called to obtain an authorization. Both are preferred providers with my health plan and they should have initiated the pre-authorization procedure. I feel that I should not be penalized for their mistake, as I did represent myself appropriately in following my health plan guidelines.
Please reconsider the charges and issue the additional payment to the hospital. Thank you for your time and consideration.