Second Level Appeal Letter Free Download


Second Level

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Health Symphony Appeal Letter

Second Level Appeal

Your name and address

Date

Address of Claims review department

RE: Name of Insured:
Plan ID #:
Claim #:

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.

Sincerely,

[Insured Name]

Enclosures:
A statement of medical necessity from your medical provider
A copy of your original appeal letter