Enrollment Exception Appeal Letter Free Download


Enrollment Exception

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Appeal Letter Displayed for Your Convenience


Health Symphony Appeal Letter

For Enrollment Exception

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 for this medical procedure stating that [patient name] was not eligible under this plan and therefore no benefits were payable.

Option 1: Choose Most Appropriate Option “I understand that there is a specified timeframe in which to enroll my newborn to my plan’s coverage and I had every intention to comply with this requirement. However, due to my postpartum illness, I was physically unable to complete this process. I have attached a letter from my physician explaining my medical situation, which states that {I was unable to perform normal daily functions or I was hospitalized during the time that the enrollment forms needed to be completed}.

Option 2: Choose Most Appropriate Option “I was diagnosed with a postpartum illness following the birth of my newborn and during this time, I was never advised of the requirement to enroll my newborn to my plan. I inquired about newborn coverage prior to my hospitalization from my {insurance agent or human resources department at my employment} and was advised that enrollment would occur automatically to my health plan. As my employer also knew that I was hospitalized to give birth to my child, they should have advised me of my requirement to enroll my newborn. As a result, I feel I should not be penalized because I was not notified of this.

I respectfully request that you take my physical inability to comply into consideration and extend me an exception to this policy requirement. I am prepared, with the assistance of my physician, to provide any necessary documentation to support this statement.

Thank you for your time and consideration.

Sincerely,

[Insured’s Name]

Enclosures:

Statement of medical illness from your physician on your behalf