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Thread: Auth Appeal Letter

  1. #1

    Default Auth Appeal Letter

    AAPC: Back to School

    I am in need of a template or sample of an a letter appealling a denial for no authorization obtained.I have a denial from a carrier and am stumbling over exactly how to word this, so a sample, (all info redacted) would be soooo appreciated. Thanks!!
    Amethyst LaFleur, CPC

  2. #2

    Default Auth Appeal Letter

    I don't have a letter exactly regarding authorization appeal, but something like this can be used to adapt for your circumstances:

    >>Dear Sir:

    We are appealing your decision and request reconsideration of the attached claim that you denied on (date).

    We feel these charges should be allowed for the following reason(s):

    (insert reasons)

    Thank you for reviewing and reversing this claim denial. If you require any additional information, please contact me at (telephone number) in our office.


    Or, this one that is geared for a patient who verified benefits and then got a denial:

    >>I called and spoke with [Contact Person] and asked about benefits for [the medical procedure]. She not only told me that it was a covered service, she also assured me that it would be paid.

    I feel that I should not be penalized for receiving incorrect information from your insurance company. I was using the customer service number provided to all members of the insurance plan and I believe that the insurance company should be held accountable for what is quoted to its members over the phone. Furthermore, based on the policy booklet, [the medical procedure] is not one of those items listed as non-covered

    My physician performed a medical procedure that is medically necessary and have included the statement of medical necessity with this letter. I hope you will reconsider your denial and pay for all of my outstanding claims associated with this procedure. Please review this letter and reconsider the charges you have previously denied. Thank you for your time and assistance in this matter.


    Or this one where the provider letter restates the medical necessity of the procedure:

    >>Dear :

    On (date), I recommended (test/procedure) for (patient) to be performed on (date). On (date), your plan issued a denial for authorization of payment. However to enable me to continue to provide my patient, (state name) with quality care, I request that you reconsider your determination due to the following factors:

    (list with bullets points)

    It is my medical opinion, that a (test/procedure) is very important in the overall care for this patient. Patient Name has been diagnosed with (diagnosis). The (test or procedure) is necessary to (state reason).

    I am forwarding a copy of this letter to (patient) and requesting (patient) to obtain the (test/procedure) despite your refusal to authorize for reasons set forth in this letter and in prior discussions.

    Sincerely, >>

    Hope these help you.

    Cyndee Weston, CPC, CMC, CMRS
    American Medical Billing Association
    AMBACode Coding Software
    2015 AMBA National Medical Billing Conference

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