For Modifier 22 Appeal Free Download

For Modifier 22 Appeal

Download "For Modifier 22 Appeal Letter " Word Document

Appeal Letter Displayed for Your Convenience

Health Symphony Appeal Letter

For Modifier 22

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 additional payment for this medical procedure, even though it was submitted with modifier 22.

I have enclosed the [operative and pathology reports] with the resubmitted claim for your review. This procedure involved extenuating circumstances which extended the time involved in completing this medical procedure. [Explain the circumstances for the additional time involved with this procedure].

Thank you for your time and consideration. If you have any questions, please contact the medical provider at [phone number].


[Insured’s Name]

Copy of claim
Operative and pathology reports, if applicable
Explanation from the physician of any extenuating circumstances