Use this letter as a
guide when appealing a health insurance claim denial based on out-of-network benefits.
In order for the letter to be effective, you should personalize it by putting
it into your own words.
Rewrite the letter, inserting your
personal information in the areas indicated in red.
You can print out this Web page and make your changes by hand or copy the body
of the letter and paste it into a document where you can make your changes on
your PC.
If you prefer to see a PDF version of the letter, click
here.
Form
letter for denial of out-of-network benefits
Date
Name
Insurance Company name
Company's Address
City, State and ZIP Code
Re: Patient's Name Type of Coverage Group
number/Policy number
Dear Name
of contact person at insurance company,
Please accept
this letter as my appeal to insurance company name decision to deny coverage for state the name of the specific
procedure denied. It is my understanding based on your letter of denial
dated insert date that this procedure has been denied
because: Quote the specific reason for the denial stated
in denial letter
I have been a member of your state
name of PPO, HMO, etc. since date. During that
time I have participated within the network of physicians listed by the plan.
However, my primary care physician, Dr. name believes
that the best care for me at this time would be state procedure
name. At this time there is not a physician within the network who has
extensive knowledge of this procedure. Dr. name of primary
care physician, a plan provider, has recommended that I have the procedure
done outside the network by Dr. name of specialist at name of treating facility.
I
have enclosed a letter from Dr. name of primary care physician explaining why he recommends name of procedure. I
have also enclosed a letter from Dr. name of specialist explaining the procedure in detail, his qualifications and experience, and several
articles that discuss the procedure.
Based on this information,
I am asking that you reconsider your previous decision and allow me to go out
of network to Dr. name for name
of specific procedure. The procedure is scheduled to begin on date.
Should you require additional information, please do not hesitate to contact me
at phone number. I look forward to hearing from you
in the near future.
Sincerely, Your
name
Reproduced
with permission from the Patient Advocate Foundation.
