For Modifier 26 Appeal Free Download

For Modifier 26 Appeal

Download "For Modifier 26 Appeal Letter " Word Document

Appeal Letter Displayed for Your Convenience

Health Symphony Appeal Letter

For Modifier 26

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 examination, because it was submitted with modifier 26.

I had a [radiological, pathology, laboratory – select one] examination as ordered by my primary care physician. The technical component of this examination has been considered and paid by [Health Plan], however, the professional component of this examination has been denied.

I have conducted research on this type of denial and have found that most health plans do pay for the professional component of a medical examination procedure. Even Medicare accepts the professional component and it is included in their fee schedule. Most health plans accept Medicare’s decisions on claims as the standard in the industry.

Please reconsider this claim and pay the appropriate reimbursement. A statement by the attending physician is enclosed. 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