How Do I Draft an Insurance Denial?

When a medical claim is denied, the company can't assume the claimant will deduce that fact by not getting a response. The company must draft a denial letter and send it to the claimant. This letter must detail the specific reasons for the denial. Additionally, the letter must inform the claimant of his right to question and appeal the decision. A complete letter that clearly states the reason for denial, while simultaneously letting the claimant know his rights, will protect your company in the event of litigation.

Instructions

• 1

  Insert the date and your company's name and address at the top of the letter.

• 2

  Write the claimant's name and address below the date.

• 3

  Insert a salutation. "Dear Mr./Mrs. X: is the appropriate format. Use a colon as opposed to a comma, since this is a formal business letter.

• 4

  Begin the letter with a paragraph reciting the claim, the date it was made and the fact that it was denied. Continue the paragraph citing the reason for the denial. For example, the procedure was performed for cosmetic reasons as opposed to medical ones.

• 5

  Write a new paragraph detailing what factors you considered in making the decision. An example is "The decision is based on the company's policies regarding cosmetic and reconstructive surgery."

• 6

  Inform the claimant that she has the right to appeal. Give her instructions on how the appeal may be completed. Include an address to send correspondence and a number to call.

• 7

  Advise the claimant of the appropriate department and number to which he can direct any questions.

• 8

  Type "Sincerely," and hit "Enter" four times. Type your name, hit "Enter" again and type your title.

• 9

  List everyone who will receive a copy of the letter below your title. Start with "cc:" and insert each name on a new line. For example:

  cc: Patient

  Doctor

  Service Provider

  Requester

  File

  With the exception of "File," each of the above descriptors should be replaced with the people's names.

• 10

  Insert the reference number at the bottom of the letter.

• 11

  Print the letter on company letterhead.

• 12

  Sign the letter in the space in between "Sincerely," and your typed name.