Non Emergent Claim Denial Appeal Letter Free Download

Non Emergent Claim Denial Appeal

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Appeal Letter Displayed for Your Convenience

Health Symphony Appeal Letter

For Non Emergent Claim Denial

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 stating that the care was not considered a “medical emergency”.

[Patient] was treated in the emergency room of [Facility/Hospital Name] on [Date of Service] as a result of a severe medical condition [list condition(s)]. This required for the [Patient] to be taken to the nearest emergency room facility for treatment, whereas a lack of medical attention and treatment would have been detrimental.

As this visit was both medically necessary and an emergency, the health plan should override the denial and make payment on the claim. Federal law normally defines an emergency as “acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in, placing the patient’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.” In addition, it allows a physician to make the determination for the need of emergency medical service and treatment.

This medical service meets the definition of an “emergency”. The attending physician who provided the medical service will also provide a statement of medical necessity indicating the need for emergency medical treatment. Please take all of this information into account and process the claim for payment.

Thank you for your time and consideration.


[Insured’s Name]


Statement of medical necessity from the medical provider