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Insurance Claim Refund Appeal Letter
This sample letter can be used to appeal an insurance claim refund. While it can be frustrating to have an insurance claim denied, it is important to state the reasons that your appeal are legitimate within the letter so that your case is documented. This template will walk you through the details you might want to consider including within your letter to the insurance company.

Free Sample Template
Format: Word PDF
# of Pages: 1
Printable: Yes


Insurance Claim Refund Appeal Letter TemplateForm 2605
Format: Word PDF
Category: Home Life, Finance
Type: Letter

Insurance Claim Refund Appeal Letter

[Your Name]
[Address]
[City, State, Zip]

[Date of letter]

[Name of Insurance Company]
Attn: Claims Director
[Address]
[City, State, Zip]

Re: Patient: [Name], ID#:_____________

Dear [Recipientís name],

I am writing to you today because you recently denied a claim on the grounds that the care I was provided on ___/___/_____ was determined to be not medically necessary.

I am appealing this denial of my Insurance Claim due to the denial being unjustified. After reviewing my explanation of benefits I am unable to determine the validity of your decision. As soon as possible please provide the following information to support your decision of denying my insurance claim.

∑ The name and credentials of the insurance claims adjuster who reviewed my treatment records.

∑ Please provide me with an outline of the specific records that were reviewed.

∑ A description of any records that are needed to approve the treatment that I had done.

I would appreciate it if you would review my claim again. The information that I have provided you, correctly reflects the appropriate diagnosis and treatment that I was provided by an approved care treatment center. If you are in need of any additional information or an additional medical report please let me know within the next ten business days. I can be reached at anytime at the number I have listed above.

Best regards,

[Your Signature]