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Heath
Symphony Appeal Letter
For a Non Covered Service
Your name and address
Date
Address of Claims review
department
RE: Name of Insured:
Plan ID #:
Claim #:
Dear Claims
Review Department:
I am 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 denied payment for this medical procedure
stating that it was a non-covered procedure.
I
referred to my policy booklet and there is no specific indication that
this is a non-covered service per my health plan’s guidelines.
On [Specific Date], I called and spoke with [Contact Person] and
asked about benefits for [the medical procedure]. She not only told
me that it was a covered service, she also assured me that it would be
paid.
I
feel that I should not be penalized for receiving incorrect information
from your insurance company. I was using the customer service number
provided to all members of the insurance plan and I believe that the
insurance company should be held accountable for what is quoted to its
members over the phone. Furthermore, based on the policy booklet,
[the medical procedure] is not one of those items listed as non-covered
My
physician performed a medical procedure that is medically necessary and
have included the statement of medical necessity with this letter. I
hope you will reconsider your denial and pay for all of my outstanding
claims associated with this procedure.
Please review this letter and reconsider the charges you have
previously denied. Thank you for your time and assistance in this
matter.
Sincerely,
[Insured
Name]
Enclosures:
A copy of the policy booklet referring to this medical procedure,
or lack thereof,
to which a decision made on receiving service was based
Any additional information, such as contact information, phone
number of any individual who provided advice or benefit information
A statement of medical necessity from your medical provider |
