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