Sample Appeal Letters

Appeal letters must include certain pieces of information to clearly state the problem and what you are expecting the health plan to resolve.  We have included a sample appeal letter below, which is appealing a denial by the health plan for not authorizing an emergency stay.  The appeal letter focuses on two main points, 1) that the physician and the hospital both are contracted with the health plan and had the ability to authorize the stay and did not and 2) that the patient would have complied, but under the circumstances was not physically able to do so and therefore, should not be penalized.

Always appeal an insurance denial.  Appealing with the proper appeal letter has a 40% chance of success.

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A letter to appeal a benefit penalty applied to a hospital inpatient stay.

1.    Benefit Penalty Appeal Letter

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 considered the charges and made a payment of [paid total], but this was after a benefit penalty of [amount of penalty] was deducted from the payment.

[Patient] was involved in a serious accident and transported to the nearest emergency facility.  I was unaware of a required pre-authorization procedure and under the circumstances, didn't think to investigate the policy booklet for pre-authorizing inpatient hospital stays. 

The policy booklet does state that the pre-authorization hotline must be called within [days] of the patient's admittance to the hospital for emergency situations.  However, I did provide both the hospital and attending physician my insurance information upon admittance and neither one of them called to obtain an authorization.  Both are preferred providers with my health plan and they should have initiated the pre-authorization procedure.  I feel that I should not be penalized for their mistake, as I did represent myself appropriately in following my health plan guidelines. 

Please reconsider the charges and issue the additional payment to the hospital.  Thank you for your time and consideration.

Sincerely,

[Insured’s Name]

Enclosures:
            None

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