When the payer paid less than the contracted rate. Tie your dispute to the fee schedule or contract term — vague dispute letters get ignored.
TODAY'S DATE
PAYER NAME
Provider Relations / Claims Dispute Department
PAYER ADDRESS OR FAX
RE: Formal Underpayment Dispute — Request for Reprocessing
Provider: PROVIDER / FACILITY NAME
NPI: NPI | Tax ID: TAX ID
Contract Effective Date: CONTRACT DATE
Patient: PATIENT NAME
Member ID: MEMBER ID
Claim Number(s): CLAIM NUMBER(S)
Date(s) of Service: DOS
Service: CPT CODE — DESCRIPTION
Dear Provider Relations Department,
This letter constitutes a formal dispute regarding the underpayment of the above-referenced claim(s). Payment was received on DATE PAYMENT RECEIVED in the amount of $AMOUNT PAID. Based on our participation agreement and the applicable fee schedule, the correct payment for this service is $CONTRACTUALLY OWED AMOUNT — a discrepancy of $UNDERPAYMENT AMOUNT.
Payment Discrepancy Summary:
| CPT Code | Date of Service | Contracted Rate | Amount Paid | Underpayment |
|---|---|---|---|---|
| CODE | DATE | $RATE | $PAID | $DIFFERENCE |
| CODE | DATE | $RATE | $PAID | $DIFFERENCE |
| Total Underpayment | $TOTAL | |||
Contractual Basis:
Per our participating provider agreement with PAYER NAME, executed on CONTRACT DATE, services billed under CPT CODE are reimbursed at RATE DESCRIPTION — e.g., "100% of the 2024 Medicare Physician Fee Schedule" / "the fee schedule rate of $X as amended on [DATE]". A copy of the applicable fee schedule section is enclosed.
IF APPLICABLE: This payment also appears to be inconsistent with [PAYER NAME]'s own remittance advice, which indicates the allowed amount as $[X] but applied an incorrect reduction of $[Y] without contractual basis.
Request:
We request that PAYER NAME reprocess the above claim(s) and issue additional payment of $TOTAL UNDERPAYMENT within APPLICABLE TIMEFRAME — e.g., "30 days, consistent with [State] prompt payment requirements". If you believe the payment was correct, please provide written explanation citing the specific contract provision supporting the reduced rate.
Enclosures:
Sincerely,
SIGNATORY NAME, CREDENTIALS
TITLE
ORGANIZATION
PHONE | EMAIL
Search Axlow for your payer's reimbursement policies, fee schedule methodology, and bundling rules — before you file a dispute, confirm the contractual basis.