Writing a medical insurance grievance letter is important because it lets the insurance company know that you disagree with the decisions they have handed down. It also serves as a rebuttal as to why you believe that they should cover the procedure or charges. The important thing is to make sure that the letter contains factual information and is writing in a firm tone. While it is important to be pleasant, an appeal letter needs to be strong and let the insurance company know that you mean business. They need to know that you have no intention of backing down regarding the matter at hand.
There are a few things that an appeal letter needs to include. Things like the policy number are helpful to allow them to quickly access the account. They may also need any group numbers or a claim number that has been assigned to the case. Be sure to reiterate their reason for denying the claim. Use this as a basis for the newsletter, start with the reason for their denial and then follow this with a brief history of the illness and the need for the procedure or treatment. While this letter may be included in a doctor’s letter that is attached for documentation, it helps to summarize and put things in a quick and readable format.
Was the decision a result of an error on behalf of the insurance company? If you believe this was a mistake, state the correct information that may make all the difference in whether the claim will be approved or denied. It is not uncommon for a coding error to have taken place. For instance, the insurance company may have you down as receiving one prescription medication when actually it was another one. If they are denying coverage because the medication doesn’t fit the realm of your diagnosis then this could be grounds for a denial.
Make sure to state why you believe they made the wrong decisions. If you need to go out of network to get the services you need, explain yourself well and attach any documentation necessary. The whole purpose of the letter is to ask for reconsideration. Before drafting an appeal letter, make sure to have property documentation and be ready to answer questions and fill out any packets the insurance company may ask. See sample below for more information on a typical medical insurance grievance letter.
Sample Medical Insurance Grievance Letter
Name of Policyholder
Address of Policyholder
City, State, Zip Code
Director of Claims
Name of Insurance Company
Address of Insurance Company
City, State, Zip Code
RE: Policy Number NUMBER appeal for claim denied. Claim number NUMBER
Dear Name of Claims Director:
Please accept this letter as an appeal to Blue Cross Blue Shield’s decision to reject coverage for the colonoscopy procedure. It is my understanding based on your notification of refusal of services dated DATE, that this procedure has been denied because:
A colonoscopy will not be approved more than once in a twelve month period without the presence of cancerous or precancerous cells.
As you know, I was identified as having Irritable Bowel Syndrome on DATE. Currently Dr. Jonas believes that I will considerably benefit from a second colonoscopy. Please see the enclosed letter from Dr. Jonas that discusses my medical history in more detail.
I believe that you did not have all the necessary information at the time of your initial review. I have also included with this letter, a follow up letter from Dr. Jonas from OSU Medical Center. Dr. Jonas is a specialist in Columbus, Ohio and he is one of the top ranking individuals in his field. His letter discusses the procedure that is needed in more detail. Also included are my medical records, explaining why this additional procedure is necessary.
Based on the current information, I am requesting that your company reconsider allowing this procedure and cover my colonoscopy as Dr. Jonas outlines in his letter. The treatment is scheduled to take place on DATE, pending your approval. Should you require additional information, please do not hesitate to contact me at 555-710-3456. I look forward to hearing from you regarding this matter.
Signature of Policyholder
Name of Policyholder Printed
List of Enclosures
By Andre Bradley