ࡱ> 8:7  bjbjWW 4==>>V$<>>>>>>}">&&&>S&<&<: ,pHT<<:8 (i0B.$vd$pp$8&&&&&&&>>&&&&&&&$&&&&&&&&&> G: Example letter for a not medically necessary denial Situation: A medical provider billed you for a denied claim. You decide to appeal the denied claim since you asked how much it would cost before receiving the services and the doctor who is contracted by the plan told you the plan would cover the ultrasound after a $30 copay.  [Your name, address, policy number] [Date] [Contact information for your insurers appeals department] To whom it may concern: Im appealing your companys decision to deny payment to Dr. Wilson for the ultrasound I received on 3/14/13 Claim No. 2596BG. The reason listed on the denial is not medically necessary. Before I had the ultrasound, I asked Dr. Wilsons office, which is a contracted provider, how much would I have to pay out of pocket for the ultrasound. His office said I would be responsible for only a $30 co-pay. Attached youll find the letter from my doctor describing: Why he found it medically necessary to perform the ultrasound. The chart notes from my office visit. The recommendation of why I should have this ultrasound. A recent article explaining that ultrasounds for situations like mine (high enzyme count in the liver) are standard-practice. Please let me know if you need any other information to review my case (via phone: 253-555-7890). I look forward to rectifying this outstanding bill in a timely manner. Sincerely, [Your name] [Your phone number] 567BI ' ? M N R u v } ~ A B ̵mmmmOmmm9+h)B*CJOJPJQJaJmH ph333sH :jh-h-B*CJOJPJQJUaJmH ph333sH +h 40B*CJOJPJQJaJmH ph333sH 1h-h-B*CJOJPJQJaJmH ph333sH 0h 40h-B*CJOJPJQJ\mH ph333sH -h 405B*CJOJPJQJ\mH ph333sH 2h-h-5CJKH$OJPJQJ\aJmH sH 2h 40h-5CJKH$OJPJQJ\aJmH sH 67CM O P R v ~ m  G  & Fd8dd-DM [$gd{d-DM gd-xdx-DM ]x^gd-$d-D@&M ^a$gd 40B { hE+h 40B*CJOJPJQJaJmH ph333sH 1h{h-B*CJOJPJQJaJmH ph333sH 1h-h-B*CJOJPJQJaJmH ph333sH  ( p { xdx-DM ]x^gd-21h:pE/ =!"#$% DdP  3 3" 88j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH J`J ENormal dCJ_HaJmH sH tH pp - Heading 1Fd@&^F+5B*CJ"KH$OJPJQJ\^JaJ"ph33DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List `` -Heading 1 Char+5B*CJ"KH$OJPJQJ\^JaJ"ph33f^f -0 Normal (Web)dddx]d^dCJOJPJQJ^JaJ*W* -`Strong5\D@"D { List Paragraph ^m$PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  B    8@0(  B S  ? OLE_LINK1 OLE_LINK2 OLE_LINK3 OLE_LINK4CC66MMFK:CZb3333RStuw}AB{E'Tqq+h^`OJQJo(hHhT^T`OJQJ^Jo(hHoh$ ^$ `OJQJo(hHh ^ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHhd^d`OJQJo(hHh4^4`OJQJ^Jo(hHoh^`OJQJo(hH  ^ `CJOJQJo(\ \ ^\ `CJOJQJo(,,^,`CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(ll^l`CJOJQJo(<<^<`CJOJQJo( ! !^ !`CJOJQJo(TqqE'         jc+xl35W  qQOj5WqQOPPPc+x 40:oE{!-)}@h@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7. [ @Verdana7.@Calibri?= *Cx Courier New;WingdingsA$BCambria Math"qhVR#'R#'   20L3QHP $P-2!xx5Example letter for a  not medically necessary denialA medical provider billed you for a denied claim. You decide to appeal the denied claim since you asked how much it would cost before receiving the services and the doctor who is contracted by the plan told you the plan would cover the ultrasound after a Wendy Gallowaydavidl  Oh+'0 ,8 X d p|8Example letter for a not medically necessary denial A medical provider billed you for a denied claim. You decide to appeal the denied claim since you asked how much it would cost before receiving the services and the doctor who is contracted by the plan told you the plan would cover the ultrasound after a $30 copay.Wendy Galloway Normal.dotmdavidl4Microsoft Office Word@vA@D|<@…D<՜.+,00 hp  (Office of the Insurance Commissioner  &Appeal letter not medically necessary Title  !"#$%&()*+,-.01234569Root Entry FT<;Data  1Table$WordDocument4SummaryInformation('DocumentSummaryInformation8/CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q