Vaccine/Medication Appeal Letter Free Download


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Appeal Letter Displayed for Your Convenience

Health Symphony Appeal Letter

For Vaccine/Medication

Your name and address


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 on these charges. Please consider this letter a formal request for review of a denial of payment for the administration of [medication name].

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 primary care physician at [phone number].

Thank you for your time and consideration.


[Insured’s Name]


Statement of medical necessity from the primary care physician

Any additional supporting documentation on the value of the medication and its

preventive treatment of disease