Download "Bundling of Procedures Appeal Letter" Word Document
Appeal Letter Displayed for Your Convenience
Health Symphony Appeal Letter
For the Bundling of Procedures
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 you denied payment on a procedure, stating that it was inclusive of another procedure being billed.
[Name of second procedure and CPT code], is not part of [Name for first procedure and CPT code]. They are separate and distinct, as described by the CPT book. I have enclosed pages from the CPT Book indicating this, as well as, a statement from the attending physician, that the services provided were inappropriately bundled together for payment.
Please reconsider and pay the additional payment on this claim.
Attending physician statement
Copy of Procedures' Descriptions from the CPT book
Any additional supporting documentation