Sample Letter of Appeal

June 21, 2011

Sometimes, decisions made are made improperly or based on erroneous information. On such occasions, a letter of appeal is appropriate. The following letter is an example of an appeal to an insurance company that denied a client his or expected benefits.

Street Address
City, State, Zip


Dear Claims Review Department:

I am writing about a claim sent to you by [Medical Provider] for [patient]. The charges were entered on [date], and they totaled [dollar amount]. [Healthcare Provider] has denied payment for this procedure, stating that the home health agency was not licensed when the procedure was conducted.

The State of Kansas does not require a home health agency to be a licensed provider. Home health agency visits are covered under my insurance plan. Therefore, I request that you reconsider your refusal to pay for this procedure. I have attached written documentation that supports my position.

Please reconsider this denial. I can supply more information if necessary or helpful; let me know what other pertinent information you may need. Thank you for your time and for your help in this matter.



Download Sample Letter of Appeal In Word Format

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