How to Write a Medical Appeal

Appealing a health insurance claim denial can be annoying and challenging. An error rate of 7 percent to 10 percent exists when a health care plan processes a medical claim, so some claim denials are evident. However, other medical claims are more difficult to appeal. Because the success rate of appealing a medical claim can be as high as 40 percent to 50 percent depending on how well the letter is drafted, the effort is worth it, according to HealthSymphony.com.

Things You'll Need

• Doctor's letter
• Medical record information
• Dictionary
• Grammar book

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Instructions

• 1

  Write the date on which you are drafting your appeal letter. Then, write your name and address followed by the name and address of the claims review department of the health insurance company that denied your medical claim.

• 2

  Write "Dear Claims Review Department" as your greeting. Mention in the first sentence of the letter your name and your medical plan identification numbers such as your subscriber number, group/policy number or claim number. Also, include the date of your medical service, the cost of the service and the name of your medical provider.

• 3

  State the reason why your medical claim was denied as explained in the denial letter you received. Use the exact wording the health plan used in its denial letter.

• 4

  Give a brief history of the illness you had or still have. Emphasize why you underwent the treatment being debated and why it was required in your case.

• 5

  Describe why you believe the decision to deny your medical claim was wrong. For example, if your medical provider has documentation it submitted your medical claim on time, explain this. Read through the health plan's policy book and try to use the plan's language when explaining why the denial should be overturned.

• 6

  Tell the claims review department what you want the managed care plan to do. For example, ask the health care plan to reconsider the claim for full payment within a certain number of days. Mention that you will contact an attorney or your state department of insurance if the health care plan does not reconsider your medical claim.

• 7

  Include a letter from your doctor or medical specialist that provides specific information related to your case. Also, include medical record information that supports your position such as radiology/pathology reports, an electronic claim submission confirmation page or progress notes.

• 8

  Write "Sincerely" as your closing and sign the letter. Mention that you have included enclosures, and list your contact information. Read over the letter and look for errors in spelling or grammar. Make sure the letter is concise and clear.