(Insurance Company/HMO)
(Date)
XXXX XXXXX
XXXX XXXX XXXXX
XXX XXXXX, XX XXXXX
Member Name:
Member Number:
Provider Name:
Service: Midface Reconstruction and Oral Surgical Splint
Referral Number: XXXXXXXXXXXX. XXXXXXXXXXXX
Dear XXXX:
Thank you for your patience and cooperation during our review process. This letter will serve as a follow-up to your telephone conversation with Grievance Coordinator XXXXXXX XXXXX, on December 29, 2001. As you were advised, pursuant to a request made by the XXX Grievance Committee during the hearing on December 20, 2001, the committee has requested additional information pertaining to your case. As we discussed, I am currently obtaining the needed information as requested by the Grievance Committee, and will have a resolution to your case as soon as the additional information is reviewed. All efforts will be made to provide you with an outcome decision to your case within 30 days from the date of this letter.
Again, thank you for allowing the Customer Response and Resolution Department the opportunity to assist you, a valued XXX member.
If you have any questions, please feel free to call Member Services at (XXX) XXX-XXXX Monday - Friday, 8 am to 5 pm, or you may contact me directly at (XXX) XXX-XXXX. If you are outside the XXX XXXXX area, please call our toll-free number (800) XXX-XXXX.
Sincerely,
XXXXXXX XXXXX, CR Grievance Coordinator
Customer Response and Resolution Department
cc: Doctor
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This cleftAdvocate page was last updated March 25, 2014
Sample Interim Letter from Insurance Company/HMO
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