Saturday, October 1, 2011

Sample appeal letter - denied claim

Practice Name
Phone# 123-456-789

Attn: Medical Records Department
4925, Independence Parkway Suite 300
Tampa, FL, 33634

Re: Appeal of Medical Claim
Patient Name:
Health Insurer Identification Number:
Claim Number:
Call Reference Number: 91111365797111
Service Date: 09/13/2010

Dear Sir/Madam:

We are appealing your decision and requesting reconsideration of the attached claim that was denied on 12/24/2009 as "Global payment made to Facility for this service. Seek reimbursement for professional fees from facility appropriately."

We feel these charges should be allowed for the following reason(s):

• Dr. name is the only Physician who interpreted the service (Professional component only) performed at St. Petersburg MRI Outpatient Hospital on 09/13/2009. Hence Dr. name is due and eligible to get paid for the professional services that he had rendered.

• MRI Hospital has billed Careplus for a global procedure in error. This facility only performed the technical component.

Now we are requesting you to reconsider our claim, reverse the payment of professional component from the other group and reimburse Dr. X for the same. When we had a discussion with the Careplus customer service, the representative advised us to file an appeal with supporting medical documents. Herewith I have attached the Claim form, Dr. X's Intrepretation document and Careplus EOB.

Thank you for reviewing and reversing this claim denial. If you require any additional
information, please contact me at 407-745-1849 between the hours of 8:00 a.m-5:00 p.m.


(Account Receivable – Reimbursement Specialist)

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