Writing an Appeal Letter for Medical Claims (with Samples)
Use these sample appeal letters for medical claims as templates for your formal appeal letter.
Last updated on January 15th, 2022
Writing an appeal letter for medical claims is important because it lets the insurance company know that you don’t agree with the decisions they have handed down. It also serves as a rebuttal as to why you believe that they should cover the procedure or charges.
The important thing is to make sure that the letter contains factual information and is writing in a firm tone. While it is important to be pleasant, an appeal letter needs to be strong and let the insurance company know that you mean business. They need to know that you have no intention of backing down regarding the matter at hand.
There are a few things that an appeal letter for medical claims needs to include. Things like the policy number are helpful to allow them to quickly access the account. They may also need any group numbers or a claim number that has been assigned to the case. Be sure to reiterate their reason for denying the claim.
The important thing is to make sure that the letter contains factual information and is writing in a firm tone. While it is important to be pleasant, an appeal letter needs to be strong and let the insurance company know that you mean business. They need to know that you have no intention of backing down regarding the matter at hand.
There are a few things that an appeal letter for medical claims needs to include. Things like the policy number are helpful to allow them to quickly access the account. They may also need any group numbers or a claim number that has been assigned to the case. Be sure to reiterate their reason for denying the claim.
Start with the Reason for their Denial
Use this as a basis for the appeal letter, start with the reason for their denial and then follow this with a brief history of the illness and the need for the procedure or treatment. While this letter may be included in a doctor’s letter that is attached for documentation, it helps to summarize and put things in a quick and readable format.
Was the decision a result of an error on behalf of the insurance company? If you believe this was a mistake, state the correct information that may make all the difference in whether the claim will be approved or denied. It is not uncommon for a coding error to have taken place.
Use this as a basis for the appeal letter, start with the reason for their denial and then follow this with a brief history of the illness and the need for the procedure or treatment. While this letter may be included in a doctor’s letter that is attached for documentation, it helps to summarize and put things in a quick and readable format.
Was the decision a result of an error on behalf of the insurance company? If you believe this was a mistake, state the correct information that may make all the difference in whether the claim will be approved or denied. It is not uncommon for a coding error to have taken place.
For instance, the insurance company may have you down as receiving one prescription medication when actually it was another one. If they are denying coverage because the medication doesn’t fit the realm of your diagnosis then this could be grounds for a denial.
Out of Network
Make sure to state why you believe they made the wrong decisions. If you need to go out of network to get the services you need, explain yourself well and attach any documentation necessary. The whole purpose of the letter is to ask for reconsideration.
Before drafting an appeal letter, make sure to have property documentation and be ready to answer questions and fill out any packets the insurance company may ask. See samples below for more information on a typical appeal letter for medical claims.
Out of Network
Make sure to state why you believe they made the wrong decisions. If you need to go out of network to get the services you need, explain yourself well and attach any documentation necessary. The whole purpose of the letter is to ask for reconsideration.
Before drafting an appeal letter, make sure to have property documentation and be ready to answer questions and fill out any packets the insurance company may ask. See samples below for more information on a typical appeal letter for medical claims.
Sample 1 - Appeal Letter for Medical Claims
DATE
Virginia Snyder
Blue Cross Blue Shield Insurance Company
9870 Cross Street
New York, NY 10024
Re: Jamie Smith
Medical Coverage –G89078723746 908765678
(Group number/Policy number)
Dear Virginia,
Please accept this letter as an appeal to Blue Cross Blue Shield’s decision to reject coverage for the colonoscopy procedure. It is my understanding based on your notification of refusal of services dated DATE, that this procedure has been denied because:
A colonoscopy will not be approved more than once in a twelve month period without the presence of cancerous or precancerous cells.
As you know, I was identified as having Irritable Bowel Syndrome on DATE. Currently Dr. Jonas believes that I will considerably benefit from a second colonoscopy. Please see the enclosed letter from Dr. Jonas that discusses my medical history in more detail.
I believe that you did not have all the necessary information at the time of your initial review. I have also included with this letter, a follow up letter from Dr. Jonas from OSU Medical Center. Dr. Jonas is a specialist in Columbus, Ohio and he is one of the top ranking individuals in his field. His letter discusses the procedure that is needed in more detail. Also included are my medical records, explaining why this additional procedure is necessary.
Based on the current information, I am requesting that your company reconsider allowing this procedure and cover my colonoscopy as Dr. Jonas outlines in his letter. The treatment is scheduled to take place on DATE, pending your approval. Should you require additional information, please do not hesitate to contact me at 740-710-3456. I look forward to hearing from you regarding this matter.
Sincerely,
Jamie Smith
Sample 1 - Appeal Letter for Medical Claims
DATE
Virginia Snyder
Blue Cross Blue Shield Insurance Company
9870 Cross Street
New York, NY 10024
Re: Jamie Smith
Medical Coverage –G89078723746 908765678
(Group number/Policy number)
Dear Virginia,
Please accept this letter as an appeal to Blue Cross Blue Shield’s decision to reject coverage for the colonoscopy procedure. It is my understanding based on your notification of refusal of services dated DATE, that this procedure has been denied because:
A colonoscopy will not be approved more than once in a twelve month period without the presence of cancerous or precancerous cells.
As you know, I was identified as having Irritable Bowel Syndrome on DATE. Currently Dr. Jonas believes that I will considerably benefit from a second colonoscopy. Please see the enclosed letter from Dr. Jonas that discusses my medical history in more detail.
I believe that you did not have all the necessary information at the time of your initial review. I have also included with this letter, a follow up letter from Dr. Jonas from OSU Medical Center. Dr. Jonas is a specialist in Columbus, Ohio and he is one of the top ranking individuals in his field. His letter discusses the procedure that is needed in more detail. Also included are my medical records, explaining why this additional procedure is necessary.
Based on the current information, I am requesting that your company reconsider allowing this procedure and cover my colonoscopy as Dr. Jonas outlines in his letter. The treatment is scheduled to take place on DATE, pending your approval. Should you require additional information, please do not hesitate to contact me at 740-710-3456. I look forward to hearing from you regarding this matter.
Sincerely,
Jamie Smith
Sample 2 - Appeal Letter for Medical Claims
Name of Policyholder
Address of Policyholder
City, State, Zip Code
DATE
Director of Claims
Name of Insurance Company
Address of Insurance Company
City, State, Zip Code
RE: Policy Number NUMBER appeal for claim denied. Claim number NUMBER
Dear Name of Claims Director,
You denied payment for a procedure that was prescribed by my doctor NAME OF DOCTOR for me after an automobile accident on DATE. The denial stated that the procedure was not medically necessary.
The denial of this claim was not justified and I am appealing it. The explanation you gave for denying the claim was not adequate, since it didn’t include any report of a medical review of my situation, nor did it include the names and credentials of the insurance representative who did review my claim.
I would like copies of any medical opinion that caused the denial of my claim, so I can have the proper medical experts respond with the applicability of this treatment for my condition. Without the physiotherapy treatment, I will not have full use of my legs.
Please review my claim again. Enclosed is a new claim application with the information about the appropriate diagnosis and treatment. I have also enclosed a letter and notes from my physician. I would like you to cover all the treatment I need to completely recover from the injuries I sustained in the accident. If you need any further information, I can be reached at 555-123-4567 or at [email protected]. I hope to get a favorable reply from you within 10 days.
Thank you for your attention to this matter.
Sincerely,
Signature of Policyholder
Name of Policyholder Printed
List of Enclosures
Sample 3 - Appeal Letter for Medical Claims
Name of Patient
Address of Patient
City, State, Zip Code
Policy Number of Patient
DATE
Name of Claims Director
Name of Insurance Company
Address of Insurance Company
City, State, Zip Code
RE: Appeal for medical claim denied to Name of Patient, Policy Number.
Dear Name of Claims Director:
This is a formal appeal letter for the denial of my claim for TREATMENT. I received the denial on DATE and the following reasons for denial were given:
The physiotherapy for my injured knee was experimental therapy and not clinically approved.
I am appealing the denial because my doctor recommended the therapy for my injury. It is an innovative treatment and considered very effective by osteopaths and physical therapists.
I have enclosed three articles in the New England Journal of Medicine that were written by experts in the field of sport’s injuries, who state that this treatment gets the best results for knee injuries than any previous treatment. I have also enclosed a letter from my doctor stating that this treatment was required for my injury.
Please reconsider your denial of payment for this treatment. If you need any further information about the treatment or from my doctor, I would like a request in writing. You can reach me at the above address or at Email Address.
Thank you for your time and consideration of my request.
Sincerely,
Signature of Patient
Printed Name of Patient
List of Enclosures: Medical Documents, Bills, Articles and Letters from Doctors
By Andre Bradley
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