Download "For Modifier 25 Appeal Letter " Word Document
Appeal Letter Displayed for Your Convenience
Health Symphony Appeal Letter
For Modifier 25
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 payment for this medical procedure, even though it was submitted with modifier 25.
I was visited by a physician for a “significant and separately identifiable evaluation and management service on the same day”, as indicated by my primary care physician. I have been informed that these procedures must be coded with a modifier 25 along with the appropriate CPT code. I have also been informed that this claim did have the modifier 25 included.
This additional medical service was necessary and appropriate care and should be fully compensated. A statement by the attending physician is enclosed. Please reconsider this claim and pay the appropriate reimbursement. If you have any questions, please contact my primary care physician at [phone number].
Thank you for your time and consideration.
The statement from the attending physician