A medical appeal letter is a written request that you or your representative send to a health insurance company or medical provider, asking them to reconsider their decision to deny coverage or payment for your medical service, treatment, or medication.
This letter explains why you needed the medical service or treatment that was denied, and includes documents to support that explanation.
The aim of a medical appeal letter is to persuade the insurer or provider to reverse their decision and provide the coverage or payment that was initially denied.
We all know that paying for the medical costs that your insurance company should cover is PAINFUL.
However, your health insurance provider may deny your medical claim, making it difficult for you to settle your medical bills.
And in case they do, you don’t have to accept their decision.
In fact, their decision is not final and conclusive.
You have the right to appeal the decision and defend your eligibility for necessary medical care.
They may have erred, misinterpreted your plan or the nature of your treatment, or denied your claim in bad faith or for improper purposes.
Writing a strong medical appeal letter to your insurance provider is one of the first steps in contesting a medical claim denial.
I have a comprehensive guide that teaches how you can appeal against your insurance company and win.
If you are interested you can read it here (recommended if you want to increase the chance of winning your medical appeal)
In this post, I will only cover the following;
- What is a medical appeal letter?
- How to write a medical appeal letter
- Medical appeal letter sample
- Medical appeal letter pdf
Jump to section
What is a medical appeal letter
A medical appeal letter is a brief statement of facts written by a patient or his medical provider (upon the patient’s request) to request the insurance provider reconsider its decision to deny the patient’s medical claim.
A medical appeal letter can help you figure out why your claim wasn’t approved and challenge that decision.
You need a medical appeal letter when
- Your medical claim was denied and you want to contest it
- You’re requesting a written statement from your doctor in order to contest a claim.
- You simply want a more detailed explanation for the denial.
My friend suffered from a severe back injury that required surgery.
His insurance company denied coverage for the procedure, citing it as elective.
We knew this wasn’t true, so we submitted a medical appeal letter (See the template) with a detailed explanation of why the surgery was medically necessary.
We included supporting documentation from multiple medical experts, and we also highlighted how the insurance company’s initial denial was based on a misunderstanding.
Thanks to the well-crafted appeal letter, the insurance company reversed its decision, and my friend received the surgery.
Today, My friend is pain-free and able to live a full and active life.
I asked for his permission to include his name and pictures but he denied it.
How to write a medical appeal letter
A medical appeal letter is written in business letter format. Begin your letter with your address and contact information, followed by a date and the insurer’s address, salute the recipient and begin your letter by indicating that you are writing to appeal against the medical claim denial and provide the grounds for appeal. Sign off with “Sincerely,” followed by your signature and name.
The following are some common reasons that you may include in your medical appeal letter as your grounds of appeal:
- That the treatment received was medically necessary
- That the insurer misunderstood your policy
- That the treatment received was recommended by a medical provider
- That the insurer’s justification is unlawful
A well-written, fact-based medical appeal letter is vital to your chances of success taking into account that only 28% of medical appeals in 2022 were decided in the patient’s favor.
But, before you start writing, be sure you know
- The deadlines for filing an appeal.
- The department or person to whom you must address your letter.
- Specific information the insurer needs from you in order to reverse the original decision.
REMEMBER the primary goal of your medical appeal letter is to appeal against a claim denial.
So, in order to write an effective medical appeal letter, do the following;
- Include your name and contact information
- Include the date of the letter
- Include the name, position, and address of the recipient
- Include the Policy number
- Include the claim number,
- State the insurer’s justification for the denial
- Describe why the insurer’s justification is incorrect (reasons for appeal)
- Attach all necessary documentation including the Medical bills.
- Provide a clear statement of what you are hoping to achieve with the appeal.
- Be simple and straightforward
- Maintain a professional tone
- Be honest
after writing your letter
- print out two copies:
- Send one copy via certified mail or any appropriate means
- Save the second copy for your records and make a note of when you mailed it and when the insurance company received it.
Medical appeal letter sample
The following is a sample of a medical apple letter to an insurance company for medical necessity
City, State, Zip Code
if you are a medical provider start with your organization’s Letterhead
Insurer Company Name
City, State Zip Code
Re: [Patient name]
DOB: [Insert Patient’s Date of Birth]
Policy Number: [Insert Patient Policy Number]
Claim Number: [Insert Patient Claim Number]
Dear Mr./Mrs./Ms. [Recipent’s last name]
I’m writing this letter to appeal against your decision to deny my $6,740 claim for an appendix operation. Based on your letter of denial dated [date], coverage was denied because [reason for denial].
I believe that your decision is improper because the treatment received was recommended by Doctor, Dr. King Lion as outlined below
- [Your diagnosis, date of diagnosis, condition, and history]
- [Previous therapies used for treating the symptoms associated with the condition]
- [Your response to these therapies]
- [Brief description of your recent symptoms and conditions]
- [Summary of Dr. Lion’s professional opinion of your prognosis and why the operation is medically necessary for you]
Enclosed with this letter is Dr. Lion’s Letter of medical necessity.
Based on the foregoing, I humbly request that you reconsider your decision and approve my claim.
Please let me know if you need any more information from me or my medical provider to review my claim.
To help you file a powerful appeal, check these Tools for proper payment & appeals from American Medical Association (AMA)
Medical appeal letter pdf
The following is a sample of the Medical appeal letter pdf free download for your personal offline use.