September 18, 2014
Non-Participating Provider

This non-participating provider appeal letter template can be tailored to fit your denial.
 
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 paid only [paid amount] due to the charge exceeding usual and customary.  
 
[I went to a facility/physician provided to me by your customer service department.  I should not be penalized for having received incorrect information from your representatives.  If I knew that this facility/physician was not participating, I would not have sought treatment from this provider.  The information given to me was made on _____ (enter date) by ______ (name of customer service representative).]
 
[I went to a facility/physician referred to me by my primary care physician/specialist who is participating with you.  As a representative of your health plan, I should not be penalized from being provided incorrect information by this medical provider.] version 2
 
Based on this information, please consider my appeal and pay my claim as if it were in network.  I have spoken with my medical provider’s business office and they have indicated that they would be willing to accept a negotiated fee for the service performed.
 
(Add only if confirmed)  
There is no question that [the medical procedure] is medically necessary, and I hope you would pay the appropriate benefit for all of my outstanding claims associated with this procedure.  Please review this letter and reconsider the charges you have previously denied.  Thank you for your time and assistance in this matter.
 
Sincerely,
[Insured Name]
 
Enclosures:
A statement of medical necessity from your medical provider


           
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