Non Covered Service Appeal Letter Free Download

Non Covered Service

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Appeal Letter Displayed for Your Convenience

Health Symphony Appeal Letter

For Non-Covered Service

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 stating that it was a non-covered procedure.

I referred to my policy booklet and there is no specific indication that this is a non-covered service per my health plan’s guidelines. On [Specific Date], I called and spoke with [Contact Person] and asked about benefits for [the medical procedure]. She not only told me that it was a covered service, she also assured me that it would be paid.

I feel that I should not be penalized for receiving incorrect information from your insurance company. I was using the customer service number provided to all members of the insurance plan and I believe that the insurance company should be held accountable for what is quoted to its members over the phone. Furthermore, based on the policy booklet, [the medical procedure] is not one of those items listed as non-covered

There is no question that [the medical procedure] is medically necessary, and I hope you would reconsider your denial and pay for all of my outstanding claims associated with this procedure. Please review this letter and reconsider the charges you have previously denied. Thank you for your time and assistance in this matter.


[Insured Name]

A copy of the policy booklet referring to this medical procedure, or lack thereof,
to which a decision made on receiving service was based
Any additional information, such as contact information, phone number of any individual who provided advice or benefit information
A statement of medical necessity from your medical provider