Sample letter for appealing a health insurance claim denial

The American Academy of Professional Coders (AAPC) estimates an average 10 to 30% of claims are ignored, lost, or denied. Denied claims cost 1 in 5 providers $500k a year. Yet, an estimated 60% of these denied claims are never resubmitted. 

The often labor-intensive process of reworking a denied claim and compiling additional documentation can deter practices from submitting an appeal. This process, however, offers the chance to reduce losses and boost revenue. 

A successful appeal begins with clear, concise communication. This letter must:

Request a physician trained in the specialty relevant to the appeal (this nearly guarantees a second-level appeal, as it’s uncommon for the insurer to have a specific specialist engaged in assessing appeals. Send the patient a copy of the letter and request their engagement to support your appeal by contacting the insurer directly. 

Revenue cycle expert, Elizabeth Woodcock of Woodcock and Associates, drafted the following sample appeal letter that is easy to customize for your specific needs.

Date 

[Insurance Company’s address] 

To Whom It May Concern:  

Thank you for the opportunity to submit this appeal for reconsideration of payment.  We are contacting you about the services rendered to [Details about the patient’s name, date of service, and services rendered].  

This service was denied on [Date]. According to the communication we received from you, the service was denied for [insert reason]. The attached documentation presents the denial, as noted in the explanation of benefits (EOB) we received. As a result, we made a subsequent communication over the telephone to [Name of Representative and Reference Code for call]. However, this letter serves to formalize our request for reconsideration of payment.   

The services rendered to the patient were denied because, according to your company, the diagnosis did not support the rendering of the service. Indeed, your company deemed the service not medically necessary for the patient. For background purposes, your insurance company defines “medical necessity” as “… a term used to refer to a course of treatment seen as the most helpful for the specific health symptoms you are experiencing. The course of treatment is determined jointly by you, your health professional, and XYZ HealthCare. This course of treatment strives to provide you with the best care in the most appropriate setting.” 

The services rendered were medically necessary for this patient. You will find the procedure notes attached to this letter. These notes highlight the symptoms that informed the decision to treat the patient in the manner performed. As the treating physician, I offer this statement:  

[Ask that your physician dictate a professional response to the denial, addressing the medical necessity of the service. Maintain a copy of this statement and letter in the event of future denials.]  

There is evidence that the services rendered were medically necessary. As published in a peer-reviewed journal, the medical literature (which is attached) supports the rendering of this service in the setting in which it was rendered.  Indeed, the services provided were the “course of treatment which was the most helpful for [Patient’s Name] health symptoms” in the “most appropriate setting”. I request a physician trained in [specialty] to review this appeal.   

In addition to myself as the treating physician, the physician who referred the patient to our practice, [Dr. ABC], supported our treatment decision. Attached is the treating physician's letter of support. We believe that the service met your criteria for medical necessity and is supported by other professionals in the field, as well as the patient’s primary care physician.  

I would be more than happy to schedule a conference call to discuss the medical necessity of this case. Please contact me at [123-456-7890] if you have any questions.  

Thank you, in advance, for reconsidering this situation. 

Sincerely,   

Dr. XYZ 

cc:  Guarantor (Patient)   

Attachments:

According to Elizabeth Woodcock, there are a few things to keep in mind to improve the chance of approval:

It’s important to note this appeal letter does not guarantee payment. This is a sample letter only. 

Rather than spending more time on appeals, a proactive approach to claim submission can help eliminate the need for corrections. Check out our step-by-step guide to reducing claim rejections and boosting your revenue.