Medical Claim Denial Appeal Letter Template (Free, Complete)

[YOUR NAME] [YOUR ADDRESS] [CITY, STATE ZIP] [PHONE] · [EMAIL] [DATE] [INSURANCE COMPANY NAME] Attn: Appeals Department [APPEALS ADDRESS FROM YOUR DENIAL LETTER] Re: Formal appeal of claim denial Member name: [PATIENT NAME] Member ID: [MEMBER ID] Claim number: [CLAIM NUMBER] Date of service: [DATE OF SERVICE] Denial date: [DATE ON DENIAL LETTER] To the Appeals Department: I am writing to formally appeal your denial of the claim above. Your letter dated [DENIAL DATE] states the claim was denied because [QUOTE THE EXACT DENIAL REASON FROM THE LETTER]. I am exercising my right to a full internal appeal under my plan and Section 2719 of the Affordable Care Act. 1. The care meets the plan's own definition of medical necessity. My treating physician, [PHYSICIAN NAME], has determined that [TREATMENT/SERVICE] is medically necessary for my diagnosis of [DIAGNOSIS]. The enclosed letter of medical necessity explains that [ONE-SENTENCE SUMMARY: what was tried and failed, and why this care is indicated]. This satisfies the definition of medical necessity in my plan documents at [SECTION, IF KNOWN — OTHERWISE DELETE THIS CLAUSE]. 2. The denial does not match the record. [STATE THE FACTS THAT CONTRADICT THE DENIAL REASON. Examples — keep only what applies: - Prior authorization: authorization was the responsibility of my in-network provider, and I ask that this claim be processed accordingly; the provider is submitting a retroactive authorization request. - Out-of-network: no in-network provider with this specialty was available within a reasonable time and distance; I contacted [PROVIDERS/DATES] and request processing at in-network benefit levels. - Not covered: the service as documented does not fall within the exclusion cited; the exclusion addresses [X], while the care I received was [Y].] 3. Supporting evidence is enclosed. Enclosed with this appeal: [LIST — e.g., letter of medical necessity dated (DATE); relevant medical records; my plan's definition of medical necessity; the denial letter]. I request that you reverse this denial and approve the claim in full. If any part of this appeal is denied, please provide the specific plan provisions, clinical criteria, and reviewer credentials relied upon, and treat this letter as my request for all documents relevant to this claim. Please respond within the timeframe required by law. If this denial is upheld, I intend to request an independent external review. [IF CARE IS URGENT, ADD: Because my treating physician has determined that a delay would seriously jeopardize my health, I request that this appeal be EXPEDITED and decided within 72 hours.] Sincerely, [SIGNATURE] [YOUR NAME] Enclosures: [COUNT]