September 22, 2017
Incorrect Diagnosis Code

This incorrect diagnosis code 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 denied payment for this medical procedure, stating that the diagnosis is [invalid or not covered].
 
Option 1: The diagnosis provided is valid for the procedure code billed.  Based on the CPT Guidelines, diagnosis  code {enter code} describes {description of the diagnosis based on the physician’s notes} and has been properly coded based on the symptoms described by the patient.  Please refer to the CPT Guidelines and reconsider the claim for payment.
 
Option 2:  The diagnosis code provided was billed incorrectly.  There was an error in the coding of this charge when billed to {health plan}.  Please accept a corrected claim with a revised diagnosis code, which is included with this appeal letter and reconsider the claim for payment..
 
Option 3:  The diagnosis code provided on the claim was correct and should be a covered expense by this health plan.  The medical records for this procedure have been enclosed with this appeal letter.  Please review this additional documentation and reconsider the claim for payment.
 
Thank you for your time and consideration.
 
Sincerely,
[Insured’s Name]
 
Enclosures:
Medical records and/or correct claim with revised diagnosis code.
Copy of the CPT Guidelines for the Diagnosis Code.
Description of the Diagnosis Code. 


        
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