August 19, 2017
Incorrect Place of Service

This incorrect place of service appeal letter template can be tailored to fit your denial. For assistance with a completely researched, focused and custom letter, call the helpline @ 920.664.9407.
 
Your name and address 
 
Date 
 
Address of Claims review department 
RE: Name of Insured:
Plan ID #:
Claim #: 
 
Dear Claims Review Department:
 
I am writing to you in regards to a claim submitted by [Medical Provider] for [patient].  The charges were rendered on [Date] and totaled [Claim dollar total].  [Health Plan] has denied payment for this medical procedure, stating that the charges were billed with an incorrect place of service.
 
Option 1: The place of service provided is valid for the procedure code billed. Based on the CPT Guidelines, procedure code {enter code} describes {description of the procedure performed based on the physician’s notes} and has been properly coded based on the type of treatment performed.  Please refer to the CPT Guidelines and reconsider the claim for payment.
 
Option 2:  The place of service code provided was billed incorrectly.  There was an error in the coding of this charge when billed to {health plan}.  Please accept a corrected claim with a revised place of service code, which is included with this appeal letter and reconsider the claim for payment.
 
Option 3:  The place of service provided on the claim was correct and should be a covered expense by this health plan.  The medical records for this procedure have been enclosed with this appeal letter.  Please review this additional documentation and reconsider the claim for payment.
 
Thank you for your time and consideration.
 
Sincerely,
[Insured’s Name]
 
Enclosures:
Medical records and/or correct claim with revised place of service
Copy of the CPT Guidelines for the Procedure Code showing a Valid POS 


           
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