Appeal letter for wrong DOS and request to reprocess the claim with correct DOS and cpt

Practice Address

Phone# 407-123-4567

____________________________________________________________

                                    03rd MAR 2010

To

Wellcare
Attn: Claims Dispute Resolution
PO BOX 31370
Tampa FL 33631-3370

Dear Sir / Madam

Sub: Appeal of Medical claim

Attachments: Claim form and Medical Documents

            ……………………

For patient (Patient name) we incorrectly billed the service date 02/06/2010 for procedure code 99221 (Initial Hospital Care). The actual service date is 02/07/2010. For the Incorrect service date 02/06/2010 (Previously billed) Wellcare paid $85.94, please reprocess the claim with service dated 02/07/2010.

When we had a discussion with customer service regarding this matter the rep suggested us to file an appeal, the call reference number is ref# 560415241234 , hence we have file an appeal with the Medical documents and Humana EOB.

In this context, we request you to kindly reverse the paid amount $85.94 for the incorrect service date 02/06/2010 and have this claim reprocessed with the correct service date 02/07/2010 and expedite reimbursements on this claim.

If you have any clarifications on this, please feel free to call us at 407-123-4567

Hoping to hear from you soon in this context.