Download "For Modifier 59 Appeal " Word Document
Appeal Letter Displayed for Your Convenience
Health Symphony Appeal Letter
For Modifier 59
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 bundled payment for this medical procedure, even though it was submitted with modifier 59.
Modifier 59 is used to clearly identify distinct, independent and separate multiple procedures. Modifier 59 was reported with CPT [code] to show that this procedure was separate from the other procedures and should not be paid as inclusive. The physician who performed this service appropriately used modifier 59.
Please reconsider this claim and pay the appropriate benefits to the medical provider. If you require additional information or have questions, please contact my medical provider directly at [phone number]. My physician will be able to provide you with additional information to validate the charges billed.
Thank you for your time and consideration.
Medical records, if requested
Additional information from the medical provider