Download "Tetanus/Other Vaccines/Injections Appeal" Word Document
Appeal Letter Displayed for Your Convenience
Health Symphony Appeal Letter
For Tetanus/Other Vaccines/Injections
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 on these charges. Please consider this letter a formal request for review of the inadequate payment made on [medication name].
[Health Plan] paid [Amount], but this payment is less than the AWP of the medication and also is less than what is normally paid for by other health plans. Please see the attached copy of the AWP for this medication. It is strongly recommended for any person aged [time frame] to receive [medication name] who - because of age or underlying medical condition - is at increased risk for complications of [disease name]. In addition, health care workers and other individuals (including household members) in close contact with persons in these high-risk groups should be vaccinated to decrease the risk for transmitting [disease name] to persons at high risk.
Please reconsider this claim and re-evaluate your reimbursement policy for [medication name]. If you require any additional information, please contact my medical provider at [phone number].
Thank you for your time and consideration.
The AWP price from the Redbook for this medication/vaccine
Statement of medical necessity from the primary care physician, upon request
Any additional supporting documentation on the value of the medication and its
preventive treatment of disease