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Timely Filing

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Health Symphony Appeal Letter

For Timely Filing

[MEDICAL PROVIDER]

[ADDRESS]

[CITY, STATE, ZIP]

[Date]

[Health Plan]

[Address]

[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 processed due to their failure to meet the applicable timely claim filing requirement.

We must follow the requirements of our Contract with [Health Plan]. In this case, we did submit our charges to you within the time frame allowed. [OPTION 1]We have enclosed a print screen copy of the billing record which is proof that the charges were billed on time. This is a permanent record in our billing system and cannot be modified. [OPTION 2] We have enclosed our electronic billing submission confirmation record as proof that the charges were billed on time.

Our physician provided medically necessary services to your member in good faith. In consideration for the services rendered, our doctor is seeking reimbursement from your office. We are requesting that you reconsider your denial of this claim and process the claim for payment.

Please know that we are doing everything possible to meet your billing requirements, as [Medical Provider] has an excellent compliance record. If you have any questions, please do not hesitate to contact me at (---) --- ----. Your cooperation is anticipated and greatly appreciated.

If you have any questions please do not hesitate to contact me at [phone number].

Sincerely,

[Name]

Business Office

Your name and address

Enclosures: Print screen copy from the billing system showing the original date billed