Download "Eligibility Version 2 Appeal Letter" Word Document
Appeal Letter Displayed for Your Convenience
Health Symphony Appeal Letter
For Eligibility Denial
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 claim stating that [patient name] was not eligible under this plan and therefore no benefits were payable.
My son was eligible under my health plan throughout, without a break in coverage. I have regularly paid my monthly premiums, these payments were accepted, insurance cards have been distributed, and claims have been paid on my behalf of my son, which means [health plan] has acknowledged eligibility for my son as a precedence of eligibility has been established. I have proceeded in obtaining medical treatment for him and claims were processed and paid. Now it appears that [health plan] is questioning my son’s eligibility and is requesting a refund from this medical provider.
This request is unacceptable and is an error. In order to properly evaluate your decision, please provide me with the name and credentials of the insurance representative who made the decision to not pay for these claims, an outline of the records reviewed and any other information used to support your decision. This appears to be an administrative issue and should not impact my ability to provide medically necessary treatment for my son, under the threat of non-payment.
Based on this information, this claim was denied in error and I respectfully request that you take this into consideration and reprocess and pay this claim in full. Failure to do so, will prompt me to file a complaint with the state insurance department or seek legal assistance. (optional wording)
Thank you for your time and consideration.