[Your Name]
[Your Address]
[Your Phone Number]
[Your Email]
[Policy Number]
[Date]
[Insurance Company Name]
[Claims Department Address]
Re: APPEAL OF CLAIM DENIAL - [Claim Number]
Member: [Your Name]
Patient: [Child's Name]
Date of Service: [Date]
Provider: [Therapist Name]
Service: [Type of therapy]
Dear Claims Review Department,
I am writing to formally appeal the denial of my claim for[child's name]'s [therapy type] services, as detailed in denial notice dated [date].
I believe this denial is incorrect based on the following grounds:
1. MEDICAL NECESSITY
[Child's name] has been diagnosed with autism spectrum disorder (copy of diagnosis attached). [Therapy type] is medically necessary for [him/her/them] to [specific reason].
A letter from [child's name]'s [doctor/psychologist] is attached confirming the medical necessity of this treatment.
2. POLICY COVERAGE
My policy, [Policy Number], includes coverage for [therapy type] under the paramedical/health practitioner benefits. The treatment provided by [provider name] falls within the covered services as described in my policy booklet.
3. PROVIDER QUALIFICATIONS
[Provider name] is a registered and licensed [profession] in good standing with the [relevant College]. Their credentials qualify for coverage under my plan.
Please reconsider this claim and provide a written response detailing your decision. If you require additional information, please contact me at [phone number] or [email].
Sincerely,
[Your Signature]
[Your Printed Name]
Enclosures:
1. Copy of diagnosis documentation
2. Letter of medical necessity from [doctor]
3. Provider credentials and registration
4. Copy of original claim and denial notice