Non Participating Refered by Participating Appeal Letter Free Download

Non Participating Refered by Participating

Download "Non Participating Refered by Participating Appeal Letter" Word Document

Appeal Letter Displayed for Your Convenience

Health Symphony Appeal Letter

For Non Participating Provider

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 paid only [paid amount] due to the charge exceeding usual and customary.

[I went to a facility/physician who was participating with you. However, they referred me to a non-participating provider who provided medical treatment to me. Unfortunately, since this provider was not in-network, my claim has been {unpaid or partially paid}. Since a participating provider from your network who is a representative of your plan, referred me to a non-network provider, I feel I should not be penalized for the selection of this medical provider. And as such, I am requesting that you pay an appropriate benefit to reduce my out of network responsibility.

{Based on this information, please consider my appeal and pay my claim as if it were in network. I have spoken with my medical provider’s business office and they have indicated that they would be willing to accept a negotiated fee for the service performed. {Add only if confirmed with your physician/medical provider.} This paragraph is optional.

There is no question that [the medical procedure] is medically necessary, and I hope you would pay the appropriate benefit 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 statement of medical necessity from your medical provider