Cleft Advocate - Sample First Insurance Denial Letter

(Insurance Company/HMO)

(Date)

XXXX XXXXX

XXXX XXXX XXXXX

XXX XXXXX, XX XXXXX

Provider Name:

Patient Name:

Patient Number:

Group Number:

Procedure: Midface Reconstruction and Oral Surgical Splint

Dear XXXX:

We have just finished our review of information regarding your provider's request for the procedure noted above. After careful consideration of all available information, we are unable to approve this request because the requested Midface Reconstruction and Oral Surgical Splint are an exclusion per your Evidence of Coverage. Therefore, we are unable to authorize this request. Please consult with your physician to discuss your treatment options. A Plan Medical Director is available to discuss this matter with your physician upon his request.

Our decision was based on (Insurance Company/HMO) Utilization Review Protocols and/or Benefits. A copy of a more detailed clinical rationale is available upon request.

If you believe this decision is not correct, you have the right to request an appeal. Expedited appeals, which are available only in certain situations, can be initiated via telephone by contacting our member Services Department at (XXX) XXX-XXXX or (800) XXX-XXXX.

To initiate a standard appeal, you may call or send a written request, together with any additional information to:

(Insurance Company/HMO Information)

(Fax)

If you have any questions regarding this notice, please contact our Member Services Department at (XXX) XXX-XXXX. If you live outside the XXX XXXX area, please call our toll-free number (800) XXX-XXXX. Representatives are available Monday through Friday from 8 a.m. to 5 p.m., PST.

Sincerely,

Medical Director

cc: Facility

PCP

Service Provider

Req. provider

File

Reference #XXXXXXXXX

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Sample First Denial Letter