Download "Second Level Appeal Letter" Word Document
Appeal Letter Displayed for Your Convenience
Health Symphony Appeal Letter
Second Level Appeal
Your name and address
Address of Claims review department
RE: Name of Insured:
Plan ID #:
Dear Claims Review Department:
On [date of first letter], I submitted an appeal for a denied claim for [name of insured]. A copy of that claim and appeal letter are enclosed. The denied charges were for medical services rendered on [Date] and totaled [Claim dollar total]. [Health Plan] has denied payment for this medical service stating that [explain original denial reason here].
I have not heard from you as to the status of my appeal [or the claim remains denied]. I am therefore requesting a hearing to resolve this issue. Your continued denial of my claim is jeopardizing my [insured’s name] access to medical care and treatment.
If you do not respond to my appeal within 15 days I will have no choice but to refer this matter to the [List State] Attorney General's Office, [List State] Department of Insurance, and may consider legal counsel.
A statement of medical necessity from your medical provider
A copy of your original appeal letter