This emergency room appeal letter template can be tailored to fit your denial.
Your name and address
Address of Claims review department
RE: Name of Insured:
Plan ID #:
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 stating that the Emergency Admission was not covered.
[Patient] was treated in the emergency room of [Facility/Hospital Name] on [Date of Service] as a result of [list condition(s)]. This required for the [Patient] to be taken to the nearest emergency room facility for treatment.
Option 1: There was not an opportunity for [Facility/Hospital Name] or the patient to obtain prior authorization from the health plan prior to receiving emergency treatment. Once [Patient] was stabilized on [Date] we did speak with a health plan representative to request an authorization on the emergency room treatment. We have since been told that the [Patient] had to be seen at a designated hospital, but due to the emergency situation we had to choose the nearest emergency room facility.
Option 2: We did speak with a health plan representative to request an authorization on the emergency room treatment, but the health plan indicated that pre-certification of the emergency room visit was not required and therefore one was not obtained. Consequently, we should not be penalized from receiving inaccurate information from the health plan.
Option 3: [Facility/Hospital Name] or [Primary Care Physician Name] is contracted with my health plan and as they are participating providers they should be aware that an authorization for my Emergency Visit should have been authorized. I did provide my health insurance information to the Emergency Room Admitting Office and they should have initiated the authorization. As such, I should not be penalized for their error.
As this visit was medically necessary, I am requesting the health plan override its denial of this claim. Additionally, I have included a statement of medical necessity from the emergency physician who is also prepared to provide a rebuttal to your decision.
Thank you for your time and consideration.