Sample Denied Claim Appeal Letter

Posted in Appeal Letters

Medical claims can be denied for a wide variety of reasons, but when you believe a reason is not justified you can send a denied claim appeal letter to your insurance company. Medical bills can be very expensive; therefore you do not want to pay anything out of pocket that should be covered by your insurance carrier. As a policy holder, you do have the right to challenge denials made by your insurance company.

Format and Content
There is some basic information that should be included in a denied claim appeal letter format. Your insurance group, policy and claim numbers should be in the letter along with your name, the date of your procedure, the name of your healthcare provider and the reason the insurance company gave for not paying the claim. Most patients and providers are notified of a denial with a letter from the insurance company or an explanation of benefits.

Sample
Tests like a PET scan (positron emission tomography) which produces 3-dimensional images of organs deep in the body and magnetic resonance imaging which produces more 2-dimensional images of organs and tissues just under the skin can be expensive. This denied claim appeal letter sample is from a patient whose insurance company denied payment on a PET scan stating that a less expensive MRI would have been sufficient to diagnosis the patient’s medical problem.

Ginger T. Richards
654 Southwest Main Street
Apt. 3B
Oklahoma City, OK 22222


Group
123


Policy
456


Claim
789
SSN 123-45-6789
555-555-5555
[email]
To:
George M. Clark
Appeals Coordinator
ABC Insurance Company
Denial Appeals Department
P.O. Box 579
Oklahoma City, OK 22222
October 1, 2013
RE: Denied Claim Appeal
Date of Service: August 15, 2013
Physician: Edward G. Alexander, M.D.
Facility: XYZ Medical Center
Dear Mr. Clark,
My name is Ginger Richards and I am writing to appeal the decision of ABC Insurance Company to deny payment for my recent PET Scan ordered by Dr. Edward Alexander at XYZ Medical Center on August 15, 2013. The denial letter I received states that a less expensive MRI would have been good enough to diagnose my condition; however Dr. Alexander ordered a PET Scan due to my past history of bladder cancer. Since a PET Scan can detect changes in organs on the molecular level it made sense for a PET Scan to be ordered instead of an MRI.
I had been experiencing pain similar to that which I experienced when my bladder cancer was first diagnosed. As it turns out, the pain is the result of scar tissue that has developed as a result of my bladder surgery 6 years ago, but had my problem been a reoccurrence of cancer, it would have been discovered earlier due to the more detailed images possible with a PET Scan instead of an MRI.
Attached is a letter from Dr. Alexander explaining why he felt it was best to order a PET Scan along with my electronic medical record file which details my health history and my battle with bladder cancer. I am asking that you reconsider my claim and pay for the PET Scan that my doctor felt was necessary to determine a proper diagnosis.
Sincerely,
Ginger Richards
Ginger T. Richards
We know how to prepare a professional resume!