August 03, 2020

General Exception

This general exception 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 
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 it is not a covered benefit under my plan.
Option 1:  The current medical condition requires that this medical treatment be allowed so that I may fully recover.  This medical treatment should be a covered expense by my plan.  I am requesting that you reconsider your denial and immediately authorize it to be paid.  My Physician is prepared to provide you with documentation to satisfy your requirements of “medical necessity”. 
Option 2:  Due to the medically necessary treatment I require, I am requesting that you reconsider your denial to not pay for this medical treatment.  In order for me to fully utilize the benefits available to me by my health plan, I am requesting that you allow this treatment by exchanging them from an under-used or non-applicable benefit in my plan.  This has been accepted and documented by other health plans to serve the needs of their members and I am asking that you extend the same courtesy to me. 
As a member of [health plan] I am requesting your reconsideration of this denial and extend the coverage for me.  If there is any additional information I could provide to you that would expedite this matter, please feel free to contact me.  Thank you for your time and assistance in this matter.
[Insured Name]
A statement of medical necessity 
An article explaining the benefits of coverage and how much can be saved 
A list of benefits you would be willing to give up in exchange for additional benefits
An explanation of the costs per treatment and possible cost savings

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