Incorrect Place of Service Appeal Letter Free Download

Incorrect Place of Service

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Appeal Letter Displayed for Your Convenience

Health Symphony Appeal Letter

For Incorrect Place of Service

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 medical procedure, stating that the charges were billed with an incorrect place of service.

Option 1: The place of service provided is valid for the procedure code billed. Based on the CPT Guidelines, procedure code {enter code} describes {description of the procedure performed based on the physician’s notes} and has been properly coded based on the type of treatment performed. Please refer to the CPT Guidelines and reconsider the claim for payment.

Option 2: The place of service code provided was billed incorrectly. There was an error in the coding of this charge when billed to {health plan}. Please accept a corrected claim with a revised place of service code, which is included with this appeal letter and reconsider the claim for payment.

Option 3: The place of service provided on the claim was correct and should be a covered expense by this health plan. The medical records for this procedure have been enclosed with this appeal letter. Please review this additional documentation and reconsider the claim for payment.

Thank you for your time and consideration.


[Insured’s Name]


Medical records and/or correct claim with revised place of service

Copy of the CPT Guidelines for the Procedure Code showing a Valid POS