Sunday, September 26, 2010

Insurance Appeal for medical necessity for additional service denial

Practice address

Phone# 789-123-4567




Attn: Medical Review Department

PO BOX 1798


FL  32231

Re: Appeal of Medical Claim

Patient Name:

Health Insurer Identification Number: XJBH3012008490

Claim Number: Q100000188728928

Call Reference Number: 1-17554020352

Service Date: 11/22/2009

Dear Sir/Madam:

We are appealing your decision and requesting reconsideration of the attached claim that was denied on 04/18/2010 as "MP907 – Documentation related to the date of service is needed from your physician to support medical necessity for the additional services.”

When we had a discussion with the BCBS customer service, the representative suggested us to file an appeal with the supporting Medical documents. Herewith I have attached the claim with supporting Medical documents.

Now we are requesting you to reconsider our claim and reimburse Dr. (Provider name) for the same.

Thank you for reviewing and reversing this claim denial. If you require any additional information, please contact me at 123-456-7890 between the hours of 8:00 a.m-5:00 p.m.


Henry Samuel

(Account Receivable – Reimbursement Specialist)

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