Insurance Reimbursement Appeal Letter Sample

This letter is my formal appeal of the rejection of Claim Number _____ for Lactation Consultation Services provided to my son, (Name) on (Date) for the amount of _____.

Summary of Events: Child was born on (Date). He was discharged from the hospital on (Date) (Detail here whatever complications you had with feeding/jaundice/dehydration/re-admittance to hospital, etc) On (Date) we met with our pediatrician, (Name) and expressed concerns about breastfeeding. Dr. _______ noted that baby was struggling to thrive and referred us to Lactation Consultant, Renee Beebe, M.Ed., IBCLC. Renee provided her services on (Date). Following the consultation, I submitted all required paperwork to (name of insurance company) for reimbursement. On (Date), I received an Explanation of Benefits (referenced above), noting the claim was denied.

Call to Customer Support: On April 23rd, I called the Insurance Company customer service line with questions regarding the Explanation of Benefits dated (Date). The CSR stated that Lactation Consultations are covered by our plan under two scenarios; (a) when under hospitalization following birth or (b) if the infant is “Struggling to Thrive” and that (baby’s name) had not met either of these criteria. Additionally, the CSR also explained that even if he was eligible for the benefit, the Lactation Consultant we used is not an “In Network” provided. I informed the CSR that it is not possible to identify an “In Network” Lactation Consultant using the Insurance Company online search tool. She reviewed the tool and confirmed.

Basis of Appeal: Based on (Baby’s name) medical history and our pediatrician’s observation, (Baby’s name) was “Struggling to Thrive,” which means we met the criteria for coverage under our plan. Additionally, the question of “In Network” vs. “Out of Network” is irrelevant since it’s not actually possible to locate an “In Network” Lactation Consultant using the (Insurance Company) system. Because we could not locate a provider using the (Insurance Company) system, we used Renee Beebe, the Lactation Consultant recommended by our Pediatrician. Renee is certified by the International Board of Lactation Consultant Examiners (IBLCE), which is the recognized association in the field. If a service is covered by our plan, it’s only fair that we can have it preformed. In this case, (name of insurance company) has made that unreasonably burdensome to locate a provider, so one was selected based on the Pediatrician’s recommendation.

Additional Information: The American Academy of Pediatrics recommends that all babies be breastfed for at least one year. Additionally, the AAP recommends mothers and babies be seen by a board certified lactation consultant when breastfeeding difficulties occur. The AAP also recommends that third party insurance reimbursements be made for lactation help.

Thank you to the parents who provided this sample letter so that other parents may be reimbursed for lactation services.  All of my clients receive an insurance claim form and are encouraged to file a claim with their insurance company.  Many insurance companies are now covering my consultations.  If a claim is denied, appeals are often successful.  In the state of Washington, you may also file a complaint with the insurance commissioner, http://www.insurance.wa.gov/consumers/ For more information, contact Renee Beebe, M.Ed., IBCLC.

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2 Responses to “Insurance Reimbursement Appeal Letter Sample”

  1. Diane Diaz Says:

    This is a very nice sample,tips and guidelines on how to write a appeal letter .Thanks for sharing it with us.I’m pretty sure a lot of people out there will find this blog of yours very helpful.

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