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Extension Of Benefits

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Health Symphony Appeal Letter

Extension of Benefits/Benefit 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 only [number in policy booklet] visits are allowed under my plan, and therefore, additional visits are not covered.

Option 1: On [Specific Date], [patient name] had an injury, which resulted in [medical condition]. Due to this accident/injury [patient name] requires additional therapy sessions to fully recover to a pre-accident level. This rehabilitative therapy should be a covered expense by his/her/my plan. I am requesting that you reconsider your denial for these additional sessions and immediately authorize them.

Option 2: Due to the medically necessary treatment required by [patient], I am requesting that you reconsider your denial to not allow at least [number in policy booklet] for therapy. In order for [patient] to fully utilize the benefits available to him/her/me by his/her/my health plan, I am requesting that you allow the additional sessions by exchanging them from an under-used or non-applicable benefit in his/her/my plan. This has been used and documented by other health plans to serve the needs of their members and I am asking that you extend the same courtesy to [patient].

As a member of [health plan] I am requesting your reconsideration of this denial and extend the coverage towards this medical treatment and service. If there is any additional information I could provide to you that would expedite this matter, please feel free to contact me. Thank you for your time and assistance in this matter.

Sincerely,

[Insured Name]

Enclosures:
A description of the accident or injury (if applicable). Do not use if not. (option 1)
A statement of medical necessity (option 2)
An article explaining the benefits of coverage (option 2)
A list of benefits you would be willing to remove from your coverage in exchange for additional benefits (option 2)