Insurance companies can deny claims for any number of reasons. Perhaps the procedure required pre-authorization which was not done or the procedure might not be a covered service under the patient’s plan. The insurance company may determine that the procedure was not medically necessary or the procedure may have been performed after the patient’s coverage was terminated. A patient who receives a denial, but believes the procedure should have been paid under the rules of the plan, can write an insurance claim appeal letter.
Format and Content
Upon receiving a denial that a patient believes should have been paid, the patient can appeal but should use a certain insurance claim appeal letter format. The letter should include the patient’s group, policy, claim and identification numbers, date of birth, date of service, date of denial, type of procedure that was denied and the name of the provider. The patient should explain why the denial should be reconsidered and the claim should be paid.
This health insurance appeal letter sample is from a patient who presented with severe abdominal pain in the hospital emergency room. The ER physician ran some tests and determined that the patient had very large gallstones and a diseased gall bladder. The patient was in extreme pain and the physician called in a surgeon who reviewed the patient’s tests, agreed that the gall bladder should be removed and subsequently performed the surgery to remove the organ. After hospital staff filed the insurance the claim was denied as not medically necessary and the insurance company stated that the condition could have been treated with medication instead of surgery.
89 Taylor Lane
San Antonio, TX 33333
ABC Insurance Group 202
Mr. Grant Rodgers
ABC Insurance Company
P.O. Box 6789
San Antonio, TX 33333
October 10, 2013
Re: Insurance Claim Appeal
Dear Mr. Rodgers,
I appreciate your speaking with me this morning regarding my claim number555 for my September 20, 2013 emergency gall bladder surgery that was denied by ABC Insurance Company. The denial stated that my gall bladder surgery was not medically necessary and that it could have been treated with medication instead.
Both the ER physician and surgeon believed my gallstones were too large to pass and that my gall bladder was diseased beyond the point in which it could be successfully treated with medication. I have attached all medical records including physician notes, ER notes, blood work and sonogram as well as a letter from Dr. Andrew Charles who treated me in the emergency room of XYZ Medical Center.
I am asking that you consider the unbearable pain that I was suffering, the extremely diseased condition of my gall bladder and the tremendous size of my gallstones and approve my surgery for payment. In the expert opinions of 2 trained physicians, the best course of treatment for my condition was removal of the gall bladder and not treatment with medication. Please reconsider my claim in light of all of the documentation I have attached.
Sally C. Glass