November 20, 2017
 
Incorrect Procedure Code

This incorrect procedure code appeal letter template can be tailored to fit your denial. For a completely researched, focused and custom letter, call the helpline @ 920.664.9407. 
 
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 charges were billed with an incorrect / invalid procedure code.
 
Option 1: The procedure code provided is correct for the type of service performed.  Based on the CPT Guidelines, procedure code {enter code} is a valid procedure code and is described as {description of the procedure performed based on the physician’s notes} and has been properly coded based on the type of treatment performed.  Please refer to the CPT Guidelines and reconsider the claim for payment.
 
Option 2:  The procedure 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 procedure code, which is included with this appeal letter and reconsider the claim for payment.
 
Option 3:  The procedure 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 procedure code
Copy of the CPT Guidelines for the Procedure Code describing the valid procedure code


            
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