Insurance Claim Appeal Letter

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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.

Sample

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.