For Modifier 25 Appeal Free Download

For Modifier 25 Appeal

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 #:
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, 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.


[Insured’s Name]


The statement from the attending physician