Claim Appeal Letter
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SAMPLE APPEAL LETTERS FIRST LEVEL APPEAL Your Name Address City State Zip Phone numbers Email address DATE HEALTH PLAN NAME ATTN: GRIEVANCE AND APPEALS DEPARTMENT ADDRESS CITY STATE ZIP RE: First Level Appeal of Denial of Medically Necessary Treatment Claim number: Member/Subscriber Name: Member/Subscriber No.: Group no.: Dear Grievance and Appeals Manager: I am writing to appeal the health plan’s denial of medically necessary treatment prescribed by my physician, Dr. .. Denial Letter c: The Honorable (Legislators name), address, city, state zip The Honorable (Regulatory Agency Commissioners name), address, city, state zip Your Physician’s name, address, city, state zip SECOND LEVEL APPEAL Your Name Address City State Zip Phone numbers Email address DATE HEALTH PLAN NAME ATTN: GRIEVANCE AND APPEALS DEPARTMENT ADDRESS CITY STATE ZIP RE: Second Level Appeal of Denial of Medically Necessary Treatment Claim number: Member/Subscriber Name: Member/Subscriber No.: Group no.: Dear Grievance and Appeals Manager: I am writing to initiate a second level appeal of the health plan’s denial of medically necessary treatment prescribed by my physician, Dr. ..
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