Download "Out Of Network Referal Denial Appeal Letter" Word Document
Appeal Letter Displayed for your convenience
Health Symphony Appeal Letter
For Out Of Network Referral Denial
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 denied payment for this medical procedure stating that it there was no referral for an out of network service, and therefore, was not payable.
[I went to a facility/physician who was out of network because there was not an in-network facility/physician who could offer me the appropriate medical treatment needed for my care. I exhausted a great deal of effort in searching for an in-network facility/physician who could perform a similar service, but was not successful.] version 1
[I went to a facility/physician who was out of network because it was an emergency situation, it was medically necessary, and there was not an in-network facility/physician in my geographical area that could assist me.] version 2
I feel that I should not be penalized for having received treatment, which was medically necessary. My medical provider has included a letter of medical necessity stating that the procedure and treatment he/she performed was appropriate and medically justified. [Furthermore, this medical provider is willing to accept a negotiated fee for the service performed.] Add only if confirmed
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.
A statement of medical necessity from your medical provider