Sample "Appeal Letter for Medical Claim Denial"

An Appeal Letter for Medical Claim Denial is a document that you can use if you would like to appeal a decision made by your insurance company to deny your medical claim. The purpose of the letter is to convince your insurance company to review their decision, as well as provide them with evidence that their claim denial was wrongful. Generally, this kind of letter is supposed to be completed by a patient, however, they might need a doctor's note (a letter from their doctor) to support their position. A Sample Appeal Letter for Medical Claim Denial can be downloaded below.

Your appeal letter can contain three parts:

  1. Introduction. You can start your document by introducing yourself and stating the reasons for writing.
  2. Medical Claim Details. Here you can explain why you disagree with the insurance company's decision to deny your claim, and provide evidence to convince them to review their decision.
  3. Conclusion. In the last part of the document, you can designate your contact details which includes a telephone number, postal address, and email (in case you did not include them earlier in your letter).

If you would like to provide more information to your insurance, you are welcome to include more parts in your letter.


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Sample Appeal Letter
for Medical Claim Denial
From: John Hardy
9838 Crowfield Road
St. Louis, Missouri 39489
+1 124-844-2742
[Date]
To: Life Eternal Insurance
322 Glendale Avenue
St. Louis, Missouri 48473
To Whom It May Concern,
My name is John and I am a policyholder of Life Eternal Insurance. I wish to file an
appeal concerning Life Eternal Insurance’s denial of a claim for a body fluid test. I
received an Explanation of Benefits dated July 13th stating that it wasn’t medically
necessary.
As is evident from my previous medical claims, I was diagnosed with migraine on July
2nd. Unfortunately, there is a significant impact on my daily life as evidenced by lack of
concentration. I am currently under the care of Mrs. Susan Copeland at Health Matters. In
the Letter of Medical Necessity I attached, she outlined why this body fluid test is
clinically beneficial for me. She states, “It’s urgent and important to do this test.” Please
consult her letter for more significant medical history. As well, I have included
supplemental materials regarding the nature of the procedure and some additional details
about the procedure itself and the efficacy of it for my condition.
Please thoroughly review the provided documents and reconsider the previous adverse
decision to allow coverage of a body fluid test, as this treatment was necessary to my
health. Should there be additional supporting information you require to render a positive
©
TEMPLATEROLLER.COM
Sample Appeal Letter
for Medical Claim Denial
From: John Hardy
9838 Crowfield Road
St. Louis, Missouri 39489
+1 124-844-2742
[Date]
To: Life Eternal Insurance
322 Glendale Avenue
St. Louis, Missouri 48473
To Whom It May Concern,
My name is John and I am a policyholder of Life Eternal Insurance. I wish to file an
appeal concerning Life Eternal Insurance’s denial of a claim for a body fluid test. I
received an Explanation of Benefits dated July 13th stating that it wasn’t medically
necessary.
As is evident from my previous medical claims, I was diagnosed with migraine on July
2nd. Unfortunately, there is a significant impact on my daily life as evidenced by lack of
concentration. I am currently under the care of Mrs. Susan Copeland at Health Matters. In
the Letter of Medical Necessity I attached, she outlined why this body fluid test is
clinically beneficial for me. She states, “It’s urgent and important to do this test.” Please
consult her letter for more significant medical history. As well, I have included
supplemental materials regarding the nature of the procedure and some additional details
about the procedure itself and the efficacy of it for my condition.
Please thoroughly review the provided documents and reconsider the previous adverse
decision to allow coverage of a body fluid test, as this treatment was necessary to my
health. Should there be additional supporting information you require to render a positive
©
TEMPLATEROLLER.COM
decision, please do not hesitate to contact me at +1 124-844-2742 or my physician at +1
847-827-4882. Thank you for your attention in this matter.
Your prompt consideration of this appeal is appreciated.
Sincerely,
John Hardy
[Signature]
©
TEMPLATEROLLER.COM
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