Claim Denial Appeal Letter

TODAY'S DATE

PAYER NAME
Appeals Department
PAYER ADDRESS LINE 1
CITY, STATE ZIP

RE: Appeal of Claim Denial
Patient: PATIENT FULL NAME
Date of Birth: MM/DD/YYYY
Member ID: MEMBER ID
Claim Number: CLAIM NUMBER
Date(s) of Service: DOS
Procedure Code(s): CPT/HCPCS CODES
Denial Reason Code: REMARK CODE (e.g., CO-97, PR-4)

Dear Appeals Review Department,

We are writing on behalf of PROVIDER NAME / FACILITY NAME, NPI NPI NUMBER, to formally appeal the denial issued for the above-referenced claim. The denial was received on DENIAL DATE with reason code DENIAL CODE.

Basis for Appeal:

The services rendered on DATE(S) OF SERVICE were medically necessary and consistent with the patient's diagnosis of ICD-10 CODE — DIAGNOSIS DESCRIPTION. The treating provider, PROVIDER NAME, CREDENTIALS, determined that BRIEF CLINICAL SUMMARY — e.g., "conservative treatment options had been exhausted and the procedure was the appropriate next step in care".

This claim was denied with the stated reason of: "QUOTED DENIAL REASON FROM EOB." We respectfully disagree with this determination for the following reasons:

1. REASON 1 — e.g., "The procedure meets the payer's own coverage criteria as outlined in Policy [POLICY NUMBER], effective [DATE]"
2. REASON 2 — e.g., "Clinical documentation confirms medical necessity per the payer's clinical coverage policy"
3. REASON 3 — e.g., "Prior authorization was obtained on [DATE], authorization number [AUTH #]" (if applicable)

Supporting Documentation Enclosed:

• Medical records / clinical notes for date(s) of service
• Operative report or procedure note (if applicable)
• Letter of medical necessity from treating provider
• Relevant payer coverage policy citation
• ANY ADDITIONAL DOCUMENTATION

We respectfully request that this claim be reconsidered and paid in full at the contracted rate of $AMOUNT. If additional information is needed, please contact our billing team at CONTACT PHONE or BILLING EMAIL.

This appeal must be resolved within the timeframe required under applicable state law / ERISA / plan terms. We reserve all rights to pursue further levels of appeal if this request is denied.

Sincerely,

SIGNATORY NAME, CREDENTIALS
TITLE
PROVIDER / FACILITY NAME
PHONE | EMAIL