Wrong Amount Paid Appeal Letter Free Download


Wrong Amount Paid

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Health Symphony Appeal Letter

For Wrong Amount Paid

Medical provider name and address

Date

Address of Claims review department

RE: Name of Insured:
Plan ID #:
Claim #:

Dear Claims Review Department:

We are 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 paid [enter payment], but the correct payment should have been [enter correct payment].

Per my policy booklet and information I received from [health plan], the correct payment for this procedure should have been [enter correct payment.] Due to the incorrect payment made on this claim, there is a balance remaining, which I am being charged for from my medical provider.

I should not be penalized for this administrative mistake. 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].

Thank you for your time and consideration.

Sincerely,

[Insured’s Name]

Enclosures:

None
By request, additional information from the medical provider

By request, a copy of the policy booklet or name and number of insurance

representative who provided payment information

Billing information of the claim sent originally, including billed date