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Dear
Customer Service Department:
I,
hereby, request that [name of medical group OR health plan] cover a bill I received for
[service, treatment OR procedure]. The service was provided on [date] by [name of provider
(doctor, lab, hospital, other)] to address [medical problem]. The bill I received
is for [amount] and must be paid by [date]. Since this bill should be covered by my
[medical group/health plan], therefore, I called the concerned [medical group/health plan]
on [date(s)], and spoke with [name of representative] concerning the bill, but the problem
has not yet been resolved.
I
would like to state the reasons as why this bill should be paid by [name of medical
group/health plan], namely:
- [name of
service] is a covered service under my health plan coverage terms;
- a referral
for [service, treatment/procedure] was provided by my primary care physician;
- [service,
treatment OR procedure] was performed by my primary care physician;
- [service,
treatment OR procedure] was performed by a specialist to whom I was referred by my primary
care physician;
- the
services were medically necessary;
- there are
no coverage exclusions or limitations of [service, treatment OR procedure], or that apply
to my case;
- I have met
all of my co-payment or deductible obligations under the health plan’s coverage
terms;
- I could
not get prior authorization before receiving [service, treatment/procedure] because my
health care problem was an emergency. I called my [primary care physician, health
plan/medical group] as soon as I could after receiving the [service, treatment/procedure],
as required by my health plan.
I
would like to emphasize that the [medical group/health plan’s] failure to pay the
bill violates [national/state] law which requires [applicable legal requirement]. I am
also attaching documentation supporting your responsibility for the bill. Kindly respond
in writing about the actions you will take regarding this request.
Thank
you for your prompt attention to this matter.
Sincerely,
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