Address of Claims review department
RE: Name of Insured:
Plan ID #:
Dear Claims Review Department:
I have received a denial on claims submitted on my behalf with the explanation that it was being denied due lack of authorization.
[Patient Name] was admitted to [Facility Name], which is an in-network facility with my health plan. My primary care physician [Physician Name] is also a participating provider. As members of this plan, they should know the requirements of my plan and obtain the authorization, if one was required for my [Treatment or Inpatient Stay]. However, if one was not obtained, it should not be my responsibility and I should not be penalized for their inactions.
[Patient Name] was admitted to [Facility Name] and treated in the Emergency Room. As a result of the emergency situation and severe illness/injury, [Patient Name] did not have an opportunity to obtain an authorization from [Health Plan] prior to [treatment or inpatient care]. [Patient Name] did attempt to contact [Health Plan] on [List Date and time], which was the first opportunity to obtain the authorization.
[Patient Name] was admitted to [Facility Name] and treated for [List Injury or Illness]. I have contacted [Facility Name] and they did obtain an authorization for these services. The authorization number is [List Authorization Number].
I am requesting that you take this information into account and waive your denial of the claim. Additionally, the treatment I received while I was inpatient was medically necessary and I am prepared to have my physician provide a statement of medical necessity and submit medical records to justify the reason for my stay.
Please reconsider my claim with the information obtained in this appeal letter. Thank you for your time and assistance, and I look forward to your prompt response.