This required section statesthe names and addresses of theindividuals writing andreceiving this letter.This required section requestsa description of the claimthat was denied.Press [Ctrl+F1] for moreinformation.This required section explainshow the notice of denial wasreceived.This require section statesthe reasons for writing theletter.This required section providesthe closing of the letter.
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REQUIRED TRANSFER SECTIONCount Field 1 1 TO DATE
REQUIRED OPENING SECTION (SECTION 1 OF 5) [Optional - From Address]
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Re: Claim No: Policy Owner: Patient: Policy No: :
This required section includes the names and addresses of theperson requesting information and the person to whom this letterwill be sent. The salutation and an opening paragraph are alsoincluded.Enter an X to include the name and address of the person writingthe letter.Enter the person's name. Press [F2] to select and paste a recordfrom the Address Manager. Access the Expert Guide for moreinformation.Enter the person's street address or edit the information asdesired.Enter the person's extended street address or edit the informationas desired.Enter the person's city or edit the information as desired.Enter the person's state/province or edit the information asdesired. Press [F8] to select a state from the selection box.Enter the person's zip/postal code or edit the information asdesired.Enter an X to include the person's country.Enter the country or edit the information as desired.Using the format MM/DD/YYYY, enter the date of the letter or editthe date as desired.If known, enter the personal title and name of the contact person atthe insurance company to whom this letter will be sent. Press [F2]to select and paste a record from the Address Manager.Enter the contact person's employment title.Enter the name of the insurance company to which this letter will besent. Press [F2] to select and paste a record from the AddressManager.Enter the insurance company's street address or edit the informationas desired.Enter the insurance company's extended street address or edit theinformation as desired.Enter the insurance company's city or edit the information asdesired.Enter the insurance company's state/province or edit the informationas desired. Press [F8] to select a state from the selection box.Enter the insurance company's zip/postal code or edit theinformation as desired.Enter an X to include the insurance company's country.Enter the insurance company's country or edit the informationas desired.Enter an X to include a subject for this letter.Enter a subject for this letter or edit the information as desired.Enter an X to include the claim number, the name of the policyowner, the name of the patient, and/or the policy number.Enter the claim number, if available. If you received writtennotice of the denial, the claim number will probably be listed onthe denial.Enter the name of the owner of the policy. For example, anindividual, or an employer if the policy is a group employee policy.If applicable, enter the name of the patient.Enter the insurance policy number. This information is usuallyprovided with the notice that denies your claim.Enter the salutation or edit the information as desired. Press[F8] to select a salutation from the selection box. NOTE: If thesalutation or the following name field is left blank, it will not beprinted.If desired, enter the name of the individual to whom this letter isbeing sent or edit the information as desired. If this field isleft blank, it will not be printed.
Denial of Insurance Claim Dear Sir or Madam
REQUIRED CLAIM DESCRIPTION SECTION (SECTION 2 OF 5) On , a claim was filed with you regarding On , I received notice that the claim was denied.
This required section gives the date the claim was filed, detailsabout the claim, and the date the notice of denial was received.Using the format MM/DD/YYYY, enter the date on which you filedthe claim.Explain the nature of the claim.Using the format MM/DD/YYYY, enter the date you received the noticethat your claim was denied.6
REQUIRED NOTICE SECTION (SECTION 3 OF 5) This notice was received in writing. A copy of the notice is enclosed. by telephone. The name of the person who provided the notice is .
This required section gives details about how the denial noticewas received.Enter an X if notice of the denial of your claim was received inwriting.Enter an X if a copy of the notice will be enclosed.Enter an X if notice of the denial of your claim was received bytelephone.Enter an X to include the name of the person who advised you thatthe claim was denied.Enter the name of the person who provided the notice.
REQUIRED PURPOSE SECTION (SECTION 4 OF 5) I am writing this letter because the denial failed to include an explanation. the explanation that accompanied the denial was inadequate. the claim should not have been denied. [Use this space to further explain your choice.]
This required section states the purpose of the letter and allowsfor additional explanation.Enter an X if the notice of denial failed to give ANY explanation.Enter an X if the notice of denial failed to give an adequateexplanation.Enter an X if you believe the claim should not have been denied.Use this optional paragraph to explain why the explanation of thedenial was inadequate, why the claim should not have been denied, orto add any other explanation.
REQUIRED CLOSING SECTION (SECTION 5 OF 5) Please reconsider your denial of the claim and provide an appropriate explanation. If you have questions or need additional information, please contact me at the address given above. I can also be contacted by phone at extension or extension . A fax can be sent to . Your response is expected by . cc: State Insurance Regulator , [Optional enclosure and carbon copy lines]
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This required section provides the closing of the letter andincludes phone numbers where you may be contacted. It alsogives a date by which you expect to be contacted and allows youto include information regarding any enclosures or copies.Enter an X to request that you be contacted by mail at the aboveaddress.Enter an X to include phone numbers where you can be reached.Enter an X to include a phone number where you can be reachedduring non-business hours.Enter a non-business phone number or edit the information asdesired.Enter an X to include a phone extension number.Enter a phone extension number or edit the information as desired.Enter an X to include a phone number where you can be reachedduring business hours.Enter a business phone number or edit the information as desired.Enter an X to include a phone extension number.Enter a phone extension number or edit the information as desired.Enter an X to include a facsimile number.Enter a facsimile number or edit the information as desired.Using the format MM/DD/YYYY, enter the date by which you desire aresponse from the insurance company.Enter a closing or edit the information as desired. Press [F8] toselect another closing from the selection box.The program completes the name by transferring the information froma previous section. The name can be changed without affectingearlier data.Enter an X if you plan to send a copy to the State InsuranceRegulator. Access the Expert Guide for information regarding StateInsurance Regulators.Enter the personal title and name of the State Insurance Regulatorto whom copies of this letter will be sent. For the address of theInsurance Regulator for your state, see the "consumer" listing inthe Address Manager.Enter the State Insurance Regulator's employment title.Enter the name of the State Insurance Regulator's Office to whichthis letter will be sent.Enter the State Insurance Regulator's street address.Enter the State Insurance Regulator's extended street address.Enter the city of the State Insurance Regulator.Enter the state/province of the State Insurance Regulator.Press [F8] to make a selection from the selection box.Enter the zip/postal code of the State Insurance Regulator.Enter an X to include a listing of attachments, enclosures, orpersons to whom copies of the letter are being sent.Use this space to enter information regarding enclosures or copies.Press [F8] to select a description from the selection box. Forexample, "Enclosures" or "Copy To".Use this space to enter corresponding information. For example, adescription of the enclosure(s) or the name of a party receiving acopy.
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