Download "Timely Filing Due to Inactivity Appeal Letter" Word Document
Appeal Letter Displayed for Your Convenience
Health Symphony Appeal Letter
For Timely Filing Due to “Inactivity”
[CITY, STATE, ZIP]
[City, State, Zip]
Subscriber No: [Number]
Patient Name: [name]
To Whom It May Concern:
Enclosed are claims that were submitted to you, but have not been paid as of this date. The charges were rendered on [Date of Service] and totaled [Claim dollar total]. [Health Plan] has denied payment on these charges because [Health Plan] has indicated that these claims were not appealed within the applicable appeal filing requirement.
We understand the requirements of the plan and have every intention of fulfilling these requirements. My physician was determining whether surgery was required for my condition during this time period and delayed a decision by evaluating my medical records and diagnostic tests.
My physician has determined a medically necessary appropriate course of action and has recommended surgery. My physician will provide a statement of medical necessity along with medical records and any other documentation you request to support the decision made. In consideration for the services rendered, I am seeking reimbursement from your office. Please reconsider your denial of this claim and process the claim for payment.
If you have any questions, please do not hesitate to contact me or my physician at (---) --- ----. Your cooperation is anticipated and greatly appreciated.
If you have any questions please do not hesitate to contact me at [phone number].
Your name and address
Enclosures: Print screen copy from the billing system showing the original date billed