All In One Guide For Writing An Effective Medical Claim Appeal Letter
Medical claims are an integral part of the healthcare industry, and there is no avoiding it. For the most part, medical claims smoothen out payments when it comes to their patients and healthcare providers. However, many of these claims often get denied, and we don’t have to tell you how frustrating that is.
Sending a well-drafted medical claim appeal letter on behalf of the patient is crucial for timely payments for your healthcare organization. Unfortunately, many healthcare organizations struggle with this. Hence, we have gone so far as to create three sample medical claim letters for your healthcare organization.
In addition to that, we will explain the common reasons for medical claim denials. The article also talks about how you can write and send a medical claim appeal letter efficiently. You might even learn a few ways to reduce your workload by minimizing your involvement in sending appeal letters.
3 Sample Medical Claim Appeal Letter Templates For Your Healthcare Organization
Below, we discuss three sample appeal letters for medical claim denial to help you efficiently communicate with insurance companies. Use the samples provided below for drafting your unique appeal letters.
Sample Medical Claim Appeal Letter No: 1
[Date]
[Name]
[Insurance Company Name]
[Address]
[City, Province, and postal Code]
Re: [Policy Holder/Patient Name]
[Type of Coverage]
[Policy number/group number]
Dear [Name of Contact Person At The Insurance Company],
I am writing this letter on behalf of [name of the policy holder] to appeal the decision to deny [name of medical service, procedure, or treatment] for [name of the policy holder].
If our understanding is correct, [name of the insurance provider] is denying the medical claim to [name of the policy holder] on the basis that “[cite the reason claimed by the insurance provider].” The denial letter you sent to [name of the policy holder] is attached with this mail.
We believe that it is medically necessary for [name of the policy holder] to have the [name of medical service, procedure, or treatment] to treat his/her medical condition. It is also our understanding that [name of medical service, procedure, or treatment] is covered under [name of the policy holder] ‘s health plan.
We want to point out that [name of health plan] covers all medically necessary services unless they are expressly excluded. As you are aware, these medical services are clearly described in the Evidence of Coverage authorized by the member’s PCP—[Attach relevant sections of the Evidence of Coverage].
Our medical team has confirmed that [name of medical service, procedure, or treatment] is medically necessary for [name of policy holder]. We are also attaching all the supporting medical documents with this letter.
Despite what you have stated in your denial letter, [name of the medical service, procedure, or treatment] is a covered service. Furthermore, it is expressed as a covered benefit in your [title of member handbook]. As stated before, [name of the medical service, procedure, or treatment] is not expressly excluded as a covered benefit in the Evidence of Coverage.
[Relevant sections or quotes from the Evidence of Coverage and the member handbook.] [Cite any relevant state laws that support your case]
[Describe the policy holder’s health condition and how the medical service, procedure, or treatment can help the patient. In addition to that, mention what would happen if the patient does not receive the treatment in time.]
[In case you are concerned that the medical claim provider will not cover the medical process because of the precedent, ask for the cover of an extra-contractual benefit. It will help your patient pay for the medical service, treatment, or procedure outside of the healthcare plan.]
[Make sure to request an expedited hearing for cases that require immediate treatment. Additionally, request a response from the insurance provider within 72 hours of mailing the letter. And don’t forget to attach a letter from the treating physician detailing the patient’s health condition.]
Sincerely,
[Your name]
Sample Medical Claim Appeal Letter No: 2
[Date]
[Name]
[Insurance Company Name]
[Address]
[City, State, and Postal Code]
Re: [Policy Holder/Patient Name]
[Type of Coverage]
[Policy number/group number]
Dear [Name of Contact Person At The Insurance Company],
I am writing you this letter to appeal [name of the insurance provider] ‘s decision to deny coverage to [name of the policy holder] for [name of the medical service, procedure, or treatment]. I understand from your denial letter that you have denied the claim because:
“[cite the reason claimed by the insurance provider].”
As you are already aware, [name of the policy holder] was recently diagnosed with [name of the medical condition] on [Date]. [name of the policyholder/patient] ‘s consulting physician Dr. [name of the doctor] believes that their patient can benefit significantly from [name of the medical service, procedure, or treatment].
You will find a letter from Dr. [name of the doctor] enclosed with this letter. It explains [name of the policyholder/patient] ‘s medical history and their need for [name of the medical service, procedure, or treatment].
[name of the policyholder/patient] believes that you did not have all the necessary information during your initial review of their case. Hence, [name of the policyholder/patient] has included a letter from the patient’s consulting physician, Dr. [name of the doctor] from [name of the healthcare facility].
Dr. [name of the doctor] is a specialist in [field of expertise], and their letter discusses the [name of the medical service, procedure, or treatment] in detail. In addition to that, you can also find the [name of the policyholder/patient] ‘s medical records and a couple of journal articles further explaining the procedure and its results.
[name of the policyholder/patient] urges you to reconsider your previous decision based on the new information. I would also like to inform you that the treatment for [name of the policyholder/patient] is scheduled to begin on [Date]. Hence, we request you to allow the coverage for [name of the medical service, procedure, or treatment] before the said Date.
Suppose you require any additional details regarding the patient’s health condition or treatment. In that case, you can contact [name of the policyholder/patient] at [phone number]. [name of the policyholder/patient] looks forward to hearing back from you soon.
Sincerely,
[Your name]
Sample Medical Claim Appeal Letter No: 3
[Date]
[Name]
[Insurance Company Name]
[Address]
[City, State, and Postal Code]
Re: [Policy Holder/Patient Name]
[Type of Coverage]
[Policy number/group number]
Dear Madam or Sir,
This correspondence appeals to your decision to deny coverage for [name of the medical service, procedure, or treatment] after [name of the policyholder/patient] ‘s surgery.
I would like to inform you that [name of the policyholder/patient] ‘s doctor strongly recommends [name of the medical service, procedure, or treatment] and believe it is the best option for their health condition.
In addition to that, I would also like to point out that the requested [name of the medical service, procedure, or treatment] is guaranteed under [Cite relevant state laws that support your case]
I have attached the following documents with this appeal letter:
-
- The written treatment plan from [name of the policyholder/patient] ‘s attending physician, Dr. [name of the doctor].
- A supporting letter from Dr. [name of the doctor] detailing the need for [name of the medical service, procedure, or treatment].
- Include a copy of the relevant provincial regulation concerning the medical claim.
I request you review this appeal and contact me if you need any further information. I look forward to hearing from you.
Sincerely,
[Your name]
[Your address and phone number]
Also Read: Hospital Claims Management
Common Reasons For Medical Claim Denials
As a healthcare provider, you must understand the common reasons for medical claim denials. Medical claims can indeed get denied for any number of reasons. But, generally, it is due to one of the reasons we discuss below.
Medically Unnecessary Service/Treatment/Procedure
If you regularly deal with medical claim appeal letters, you have likely come across this reason countless times. Here, the insurance company rejects your patient’s medical claim citing that the medical treatment or procedure is unnecessary.
In this case, you require a medical necessity appeal letter. It must prove to you – the healthcare provider believes the recommended treatment is necessary for the patient. It is relatively easy when the healthcare provider writes the appeal letter on behalf of the patient.
However, you must provide documentation explaining the necessity of a medical service/treatment/procedure.
Experimental Treatments
Usually, experimental treatments are not covered under medical claims. Hence, if the insurance provider thinks that your patients are receiving experimental treatments, they will deny the patient’s medical claim. In this case, there are a few ways you can convince the insurance provider to approve the patient’s claim.
- Explain in your medical claim appeal letter that the treatment was medically necessary
- Prove that the medical procedure or treatment conducted is standard in the medical community
- Elaborate on how it is the only treatment that can work for the patient’s unique health condition
- Prove how the new treatment is less expensive than the standard one
- Show in your medical claim appeal letter that the procedure was covered for past patients with a similar or identical medical condition
Healthcare Setting (Homecare, Hospitalization, etc.)
Many medical claims get rejected when patients require in-home care instead of hospitalization. But, a significant amount of these cases may actually be covered under the patient’s medical claim. Usually, all it takes to approve the lawsuit is to show that in-home care is less expensive than hospitalization.
However, you should also use the medical claim appeal letter to explain that in-home care can meet patients’ medical needs. As long as you approve the letter as the patient’s healthcare provider, there should be no problem claiming the insurance.
Policy Cancellation Due To Lack Of Payment
Unlike the other medical claims we discussed above, the healthcare provider does not play a vital role in this one.
However, you can still help the patient with their medical claim appeal letter. For instance, you can try explaining why the payments weren’t made, such as technical problems or errors in payroll.
In this case, the medical claim is much more dependent on the policyholder than your healthcare organization.
External Review By An IRO Or Independent Review Organization
An external review is warranted when the patient runs out of an internal review process from their insurance provider. In such cases, the patient can use the appeal process for an external review by an IRO or Independent Review Organization.
How To Write An Appeal Letter For Medical Insurance Claim?
You need to consider three aspects when writing a medical claim appeal letter. One is the essential elements you include in the letter. The next is explaining the reason why your patient deserves a medical claim. The final part is sending the submission to the insurance provider.
Essential Elements of Medical Claim Appeal Letter
- Patient’s name and policy number
- Contact information for the patient and policyholder
- Details of the denial letter include the Date, cited reason for denial, etc.
- Name consulting doctor or healthcare provider and their contact information
Explaining Why Your Patient Deserves The Medical Claim
- Explain why the patient needs the prescribed medical service/treatment/procedure
- Tell why you believe the claim is warranted in the medical claim appeal letter
- A letter from you (healthcare provider) is explaining the medical necessity
- References of published journals, articles, etc., that support your appeal letter
Sending Your Submission
- Use certified mail to submit your medical claim appeal letter via postal mail
- Track your appeal letters once you submit or send them
- Keep a copy of your letter and all other submitted documents/materials
- Contact the insurance company if you don’t get confirmation on receiving the letter
Using Automated Direct Mail For Sending Medical Claim Appeal Letter
The most efficient way for healthcare organizations to send medical claim appeal letters is to use an automated direct mail system like PostGrid. Every aspect of sending the submission listed above is simplified when you employ a tool like PostGrid.
Everything from tracking your letters to accessing a copy of your medical claim letter becomes significantly easy. You can use PostGrid’s dashboard to access all your information at any given time. Furthermore, PostGrid comes with PIPEDA, SOC – II, and HIPAA compliances.
You can send letters securely to addresses within Canada and outside it. The fully automated nature of the tool ensures that there is minimal error leading to seamless direct mail communication for your business.
Writer’s Note: Submitting your direct mail letters, including medical claim appeal letters, is significantly easier using PostGrid‘s direct mail automation tool.
