HTML Preview Rejection Request Letter page number 1.
REFUND REQUEST REJECTION LETTER
Note:
! If you are a contracted provider, use the entire second sentence (yellow + green)
! If you are NOT a contracted provider, use only the yellow portion of the second sentence
! Remove the highlighting and insert the appropriate info in brackets before sending "
[~Current Date~]
Attn: Director of Claims
[~Insurance Policy #1 Carrier~]
[~Insurance Policy #1 Address~]
Re: Patient: [~Patient Name~]
Policy: [~Insurance Policy #1 Number~]
Insured: [~Responsible Party Name~]
Dates of Service: [~First Service Date~] - [~Last Service Date~]
Amount: [~Total Charges~]
Dear Director of Claims,
We are in receipt of a refund request regarding the above referenced claim. This letter is to formally appeal your
request for repayment based on our contractual rights as an in-network provider for [Insurance company name].
According to our records, the books are closed on this claim and your company many not have legal standing to
enforce the refund/recoupment request. According to our review, the claim was paid appropriately and no credit
balance is on the account. Further, we have applied all applicable contractual adjustments and have billed the patient
for any applicable patient responsibility. It is our position that the legal theory of laches may prohibit your request
for repayment.
Laches is a legal doctrine which, according to Barron's Law Dictionary, Third Edition, provides protection to a party
with an equitable defense in situations where long-neglected rights are sought to be enforced against a party.
According to general legal rules, as an innocent creditor, we cannot be held liable for mistakes on the payor's part.
We obtained the patient's insurance card provided at the time of service and based on that, believed we were entitled
to third party payment from your company. We received the payment and explanation of benefits in good faith, and
based on that, did not bill the patient for the portion covered by insurance. We provided services in good faith and
the funds received have been exhausted. Now, a reimbursement of the insurance benefit to you would seriously
jeopardize our ability to collect the debt from the patient.
Further, your company has not provided sufficient documentation to support the request, including a copy of the
policy or plan terms, the date the error was detected and by whom and proof that the patient is aware and agrees with
the action taken on the policy.
We feel that we have been properly reimbursed for services rendered and no refund will be issued. If, in the future,
you elect to deduct the alleged overpayment from future benefits to be paid, we reserve the right to consult further
legal counsel in order to insure that our full rights, which may or may not be addressed in this letter, are preserved.
Please do not hesitate to call me if you have any questions or need additional information.
Sincerely,