Sample Letter of Appeal
(Practice Letterhead)
(Date)
(Payer Name)
(Payer Representative)
(Payer Address)
(City, State ZIP Code)
(Payer Fax Number)
Attention: (Payer Representative)
Attention: (Claims Department)
Re: Coverage of (Product Name) (Generic Name)
Subscriber: (Subscriber's First and Last Name)
Patient Name: (Patient's First and Last Name)
Policy # / Patient ID: (Policy Number / Patient’s ID)
Group #: (Group Number)
Patient Date of Birth: (Patient Date of Birth)
Treatment Date: (Treatment Date)
Claim #: (Claim Number)
Amount of Claim: (Amount of Claim)
Dear Director of Claims:
I am writing to request a review of a denied claim for (Patient’s name). Your company has denied this
claim for the following reason(s), listed on the attached Explanation of Benefits (EOB):
(Fill in reason(s) from EOB)
(Mr/Mrs/Ms) (Patient’s name) was provided with (Product Name). The full Prescribing Information for
(Product Name) can be accessed at www.(product name).com.
Summary of Patient History (you may want to include):
(Provide diagnoses, dates of service, outcomes, and rationale for treatment. NOTE: Physicians
should exercise medical judgment and discretion in regard to making an appropriate diagnosis
and characterization of an individual patient's medical condition. In addition, physicians are
responsible for ensuring the accuracy and validity of all billing and claims for appropriate
reimbursement.)
Treatment with (Product Name) has been a necessary therapy for this patient’s medical condition, and it
is my clinical opinion and assessment that (Patient’s name) has benefited from (Product Name). I trust
that the enclosed information, along with my medical recommendations, will establish the medical
necessity for payment of this claim. Please call my office at (insert telephone number) if I can provide you
with any additional information to approve my request. I look forward to receiving your timely response
and approval of this request.
Sincerely,
(Physician’s name)
USA-CBU-81814
