Usual and Customary Denial Appeal Letter Free Download Appeal Letter


Usual and Customary Denial

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Health Symphony Appeal Letter

Usual and Customary Denial

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 reduced the payment of these charges due to “usual, customary and reasonable”.

I have contacted my physician who billed for these services and he/she has instructed me that the charges are appropriate for the level of acuity and intensity of the medical services provided and for the expertise required to provide these services. The charges billed for my treatment are comparable to charges by other physicians and providers who perform similar or like services.

I am aware that the term “usual, customary and reasonable” can vary substantially among health plans and there is a great deal of latitude applied to its definition. Each health plan applies a different set of criteria, including, but not limited to relative values and a comparison of charges from other physicians within a specific geographic region. However, the health plan is also influenced by the need for expenditure containment at the sake of increasing the patient’s financial liability. The result is that the patient, who must pay monthly premiums to maintain the insurance coverage, is frustrated with the lack of payment on a service that should be covered by the health plan.

Please reconsider this claim and pay the appropriate benefits to the medical provider. If you require additional information or have questions, please contact my medical provider directly at [phone number]. My physician will be able to provide you with additional information to validate the charges billed.

Thank you for your time and consideration.

Sincerely,

[Insured’s Name]

Enclosures:

None
By request, additional information from the medical provider