How To Write a Medical Claim Appeal Letter

Everything ordered by your doctor will not be covered if you have health insurance.You will need to write a letter to appeal the decision if your insurance provider denies payment for a medical procedure.Patients’ rights were increased by theAffordable Care Act.The exact reasons for denying your claim are now required of insurance companies.You have six months to appeal.If the amount of money involved is significant, you should appeal.

Step 1: First rule out simple mistakes.

A claim can be denied due to a clerical error.The easiest mistakes to correct are these.To make sure there are no obvious errors, read through the documentation from your insurance company.If you discover that someone at your doctor’s office made a mistake, contact the office staff and ask them to submit the corrected forms to your insurance company.If the mistake appears to have been made by someone at your insurance company, call them, point out the error, and ask them to send you updated documents with the correct information.If the insurance company has confused your file with someone else’s, you should check that your name is spelled correctly.To make sure they were entered correctly, check your insurance policy ID number and the date that the procedure was performed.Make sure the procedure code is correct.You may need to verify this with your doctor, insurance provider, or both if you aren’t sure.Make sure your insurance company approves your doctor for coverage by checking his or her name and information against your policy.Make sure everything is spelled correctly.Make sure the description of the services is an accurate representation of what was provided.

Step 2: Do you want your doctor to rephrase his or her statement?

If your insurance company denied a claim for a procedure that your health care provider deemed necessary, there may be a discrepancy between the wording of your doctor’s statement and the guidelines in your policy.Take the guidelines with you to your doctor’s office.It is possible for the doctor to rephrase his or her statement so that it is in line with your insurance company’s guidelines.Print out the part of your insurance company’s guidelines that relate to your case.The correct documentation can be found by using the name of your insurance company and the words “medical policies” or “clinical policies”.For convenience of practitioners, the guidelines are posted on the insurance company’s website, but also accessible to members.Your doctor will help you understand the technical jargon used by your insurance company.Ask if he or she will take a look at the entire section, if you print it out first.

Step 3: Ask your insurer why your claim was denied.

Call your insurance company to find out why your claim was denied.Don’t end the call if the agent tries to intimidate you, or if they try to confuse you.When speaking with your insurance agent, be polite and patient.If you are on friendly terms, the person who denied your claim may be more willing to help you during the process.Say, “Hello, I’m calling to understand why I received a notice that a claim for medical services was denied.”Was it possible for you to explain it to me?You should be able to give the agent some specific information about your claim.Accept that you are stressed about your claim if you get upset during the call.Tell the agent that you know the situation is not his or her fault, and apologize for losing your cool.Take a deep breath, and then say: “I’m sorry, but I hope you can understand how important this is for me to understand.”Can you explain that again?

Step 4: Request information.

You can request copies of missing documentation from your insurance company.If your insurance company made changes to your file as a result of a phone conversation, you should ask them to send copies of the new documents.The official denial letter is required.A copy of your policy coverage is required.Sometimes called the Evidence of Coverage, this document should explain the guidelines your insurance company uses to determine whether a medical procedure is medically necessary.If your insurance company has posted evidence of coverage, you can check online.

Step 5: Don’t forget to keep notes of your calls.

Keep detailed notes when talking to your insurance company.Keep your notes in the same file as your documentation, and write a short summary of the conversation.Take note of the person’s name, job title, and the date and time of their call.At the end of the conversation, ask for the call reference number.You may not need to repeat your case every time you call.The telephone agent may be able to pull up your information more quickly if you ask for the document image number.

Step 6: The agent for the insurance company can give an outline of the appeals process.

Ask your insurance company what you need to do to appeal a negative decision.You don’t need to be aggressive.A claim is just one part of the business.You will need help understanding the process.Will you please explain to me what I need to do to appeal this decision?Do you know if your insurance company requires specific forms?If they are available online, have them sent to you immediately.Details of your insurance company’s appeals process should be included in the explanation of the benefits you received.You can find the deadline for filing an appeal.The deadline should be given by the agent.Make a note of it and mark it on your calendar.

Step 7: You will need to gather all the pertinent information.

All the pertinent information should be collected in one file before you start writing.When writing a letter, you may want to refer to certain documents.In particular, get together any of the following: notes from your visit to the doctor, a copy of your insurance policy contract, any bills or notices you may have received regarding the claim, and any notes you have from prior telephone conversations.

Step 8: Your doctor can give you supporting information.

When you become aware of the problem, call your doctor’s office.You should ask for written documentation of your case, specifically outlining the procedure and why it was necessary.Your doctor could make copies of your charts for you.You can get copies of your medical records from your doctor’s office.The more proof you have, the better.

Step 9: Make copies of journal articles.

Make copies of the article if you find any information that supports your procedure.It’s important that your information is collected from authoritative, peer-reviewed medical sources.

Step 10: You should give your identifying details.

Start with your name, address, policy number, claim number and any other reference numbers you may have collected that identify your case.You should include your insurance policy number, admission and discharge dates, and the exact amount of charges you are claiming.If you want to provide this information in a reference line at the top of your letter, you should not include it in the sentence form.In a standard business letter, your name and address will appear at the top of the page, followed by the appeals office’s address.Then, a line or two below the address.Policy No. 12345.A678.Continue with your letter, “Dear Sir or Madam.”

Step 11: The letter should be addressed to the director of claims.

The date the services in question were rendered should be noted in the first paragraph of the letter.If your insurance company has a specific person to whom appeals should be directed, you should address your letter to that person.Explain your situation: “I am a patient of Dr. Smith, and I am writing to appeal the denial of a procedure he performed on July 1, 2016.”

Step 12: Write down the situation in your own words.

Explain how your medical condition affects your life.Tell your insurer why you need the procedure.Try not to show your frustration in your letter by being polite when choosing your words.It is helpful to limit yourself to factual information in a letter like this.

Step 13: Why do you think the procedure should be covered?

Explain why the medical procedure should be covered by your insurance policy.Don’t use medical jargon and use your own words.If you are appealing only part of a claim, you should know which part you’re fighting.

Step 14: Give your evidence.

Why do you think the documents support your case?If you believe the service will help prevent future expenses, such as hospital readmission or problematic side effects, be sure to explain why.As you write your letter, make references to the attached documents.There are important passages in your documents.Paragraph 17 of the Insurance Policy Coverage Statement states that this type of procedure should be covered.

Step 15: Allow your claim and the company will save money.

It is important to show that paying this claim will save the insurance company money in the future.If your insurance company denies coverage for a procedure, you can try to convince them that it will cost them less money in the long run.An insurance company denies a claim to pay for equipment needed to administer medication at home via a J-tube, or alternatively to supply an alternative method for feeding the patient or administering.If the insurance company does not cover the claim of $200 per month, the only other option would be to have the patient’s many medications administered at the hospital at a cost of more than $1,000 per day.

Step 16: Request a review of a case.

Ask your insurance provider to review your claim again.If the information in the first claim was correct, tell us.

Step 17: Conclude your letter courteously.

Thank the person for their time and attention.You can reach me through my phone number, email address, or any other convenient way.You should include contact information for yourself and your doctor.”If you have any further questions about this appeal or my claim, you may contact my doctor, Dr. John Smith, at 555-6789.”

Step 18: It’s mandatory to follow up within the timelines.

You have to submit your appeal letter before the deadline.Be proactive and never expect the insurance company to follow you up.If you miss the deadline, you won’t be able to have your case reviewed.

Step 19: Attach your supporting documents.

The documentation you collected should be included in the envelope.The documents will be less likely to be lost when your letter is opened.Attach a letter from your doctor if you were able to get a rephrased statement that was more in line with the policies of your insurance company.Your doctor may have made notes about your case if you include any medical records you obtained.You should include copies of any relevant medical journal articles that support the procedure in question.

Step 20: Ask your doctor to read your letter.

Ask your doctor to read your letter before posting it if you think he or she will review your case.It is possible that your doctor will notice a missing detail or an aspect of the case that you have misconstrued.

Step 21: You can send your letter via certified mail.

You will have proof that your insurance company received your letter if you request a return receipt.You will be able to prove exactly when you mailed the letter if your letter is lost in the mail.You should keep at least one copy of the letter, the postal delivery receipt, and any correspondence pertaining to your claim.