March 18, 2018

This bundling health insurance appeal letter can be tailored to fit your own circumstances. 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 considered the charges and made a payment of [paid total], but this was after you denied payment on a procedure, stating that it was inclusive of another procedure being billed.
[Name of second procedure and CPT code], is not part of [Name for first procedure and CPT code].  They are separate and distinct, as described by the CPT book.  I have enclosed pages from the CPT Book indicating this, as well as, a statement from the attending physician, that the services provided were inappropriately bundled together for payment. 
Please reconsider and pay the additional payment on this claim.  
[Insured’s Name]
Attending physician statement
Copy of Procedures' Descriptions from the CPT book
Any additional supporting documentation

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