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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 #:
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 claim stating that [patient name] was not eligible under this plan and therefore no benefits were payable.

Option 1: Choose Most Appropriate Option “We have received a statement from [health plan] indicating that my husband [patient name] is self employed and has separate insurance coverage. However, this information is inaccurate. My husband does not have his own health insurance and he is not self-employed. He has neither purchased it nor is it provided by his employment. My husband’s employer does not offer health insurance to its employees.”

Option 2: Choose Most Appropriate Option “[Health plan] is stating that my husband has his own health insurance and is self-employed. However, this information is inaccurate. I have completed the Coordination of Benefits Form from you, which indicates that my husband does not have his own separate insurance, but is instead covered under my health plan through my work. Coordination of Benefits does not apply in this case.”

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.

Thank you for your time and consideration.


[Insured’s Name]