November 23, 2017
 
Usual and Customary

This usual and customary 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 reduced the payment of these charges due to “usual, customary and reasonable”.  
 
I have contacted my physician who billed for these services and he/she has instructed me that the charges are appropriate for the level of acuity and intensity of the medical services provided and for the expertise required to provide these services.  The charges billed for my treatment are comparable to charges by other physicians and providers who perform similar or like services.  
 
I am aware that the term “usual, customary and reasonable” can vary substantially among health plans and there is a great deal of latitude applied to its definition.  Each health plan applies a different set of criteria, including, but not limited to relative values and a comparison of charges from other physicians within a specific geographic region.  However, the health plan is also influenced by the need for expenditure containment at the sake of increasing the patient’s financial liability.  The result is that the patient, who must pay monthly premiums to maintain the insurance coverage, is frustrated with the lack of payment on a service that should be covered by the health plan.
 
We do not believe the reduction is justified.  As you are likely aware, such provider reimbursement 
rates are typically adjusted based on the usual and customary treatment charges for that specialty and 
the geographical region where treatment was provided. Further, many state and federal disclosure laws require insurers and administrators to advise beneficiaries and providers as to how the reimbursement rate is determined.  However, the payment rendered does not appear to be comparable to rates charge for this service locally and no information has been given to support your position that the denial is correct.
 
Based on this information, we request that the reductions be reversed and an additional payment be 
made.  If your company does not release additional benefits, please submit the applicable policy 
language which justifies the reduction as well as the data used to establish the reimbursement rate so 
that we may determine your company's and the patient's liability in regards to the unpaid balance.  
 
My physician has provided his/her view of the reduction applied to the charges as well as all progress notes related to the treatment in question. Thank you for your time and consideration.
 
Sincerely,
 
[Insured’s Name]
 
Enclosures:
Additional information from the medical provider and progress notes


           
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