Emergency Room Denial 2nd Attempt Appeal Letter Free Download


Emergency Room Denial 2nd Attempt

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Appeal Letter Displayed for Your Convenience


Health Symphony Appeal Letter

For Emergency Room Denial

Your name and address

Date

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 stating that the Emergency Room charges are not covered.

[Patient] was treated in the emergency room of [Facility/Hospital Name] on [Date of Service] as a result of [list condition(s)]. This required for the [Patient] to visit the nearest emergency room facility for treatment.

Option 1: Your plan indicates that an Emergency Room charge will not be covered unless it is followed by an inpatient hospital admission. However, as I did have an emergency medical condition, was treated and fortunately was able to be sent home the next night, my Emergency Visit was both medical necessary and required. In addition, by allowing me to be sent home the following night, my plan does not have to pay the additional expenses involved in an extended inpatient admission.

Option 2: [Facility/Hospital Name] or [Primary Care Physician Name] is contracted with my health plan and as they are participating providers they should be aware of the requirements and limitations of my plan for an Emergency Visit. I did provide my health insurance information to the Emergency Room Admitting Office and they should have initiated the authorization and advised me of any problems. As they did not, I should not be penalized for this error.

As this visit was medically necessary, I am requesting the health plan override its denial of this claim. Additionally, I have included a statement of medical necessity from the emergency physician who is also prepared to provide a rebuttal to your decision.

Thank you for your time and consideration.

Sincerely,

[Insured’s Name]

Enclosures:

Statement of medical necessity from the medical provider