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Specialized Appeal

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Health Symphony Appeal Letter

Specialized Appeal

Your name and address

Date

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 for this medical procedure, stating that this procedure/treatment is not a covered benefit. I am requesting a reconsideration of this denial, or would like to request an immediate hearing to explain my case.

[option 1] On [Specific Date], [patient name] had an [injury or illness described] which resulted in [medical condition]. Due to this, [patient name] requires [explain medical treatment in detail, as part of statement of medical necessity]. In the absence of this treatment, [patient name] will [explain situation of if treatment was not provided, including the explanation of additional costs, potential hospital stays, etc. ] This procedure should be a covered expense for his/her/my plan. I am requesting that you reconsider your denial and immediately authorize payment. [state if accurate] This procedure is not a dental procedure, it is a medical procedure and should be covered. [Physician name] is prepared to provide a rebuttal and is willing to speak with your representative or medical review board of my condition and treatment.

[option 2] My physician [physician name] has informed me that [health plan] has denied my treatment [describe treatment] that has been recommended to me, and further, has been deemed medically necessary for the treatment of [describe condition]. I have endured [explain situation]. I have exhausted all other potential forms of treatment [describe chronology and list other treatments]. As they were not successful, I have been advised to seek a permanent solution which requiress [treatment.] Unfortunately, due to the extent of this medical condition, this is the only available and appropriate treatment. The standard of care for this condition has been met and is further supported by a letter from my physician.

As a member of [health plan] I am requesting your reconsideration of this denial and extend the coverage towards this medical treatment and service. If this request is denied, I feel I will have no choice but to contact [state department of insurance] and may seek legal counsel. I intend to use every available means to get this matter resolved. {include if a true statement}

Sincerely,[Insured Name]