Risk Management
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Appeal Letter to MCO When Treatment is Denied (Not Covered Service)
APPEAL LETTER TO MCO WHEN TREATMENT HAS BEEN DENIED ON GROUNDS THAT IT IS NOT A “COVERED MEDICAL SERVICE”
Chairperson
Utilization Review Committee
RE: (Patient Name)
Patient ID Number
Dear:
On (Date), I prescribed (Test/Procedure) for (Patient’s Name). On (Date), you denied authorization of payment for that (Test/Procedure) on the grounds that it was not a covered medical service. I request that you reconsider your determination for the following reasons:
(List Reasons That Demonstrate Why the Test/Procedure is a Covered Service)
In my medical judgment, a (Test/Procedure) is a very important part of my overall care of (Patient’s Name). (Patient’s Name) suffers from (Describe Condition). In addition to being a covered benefit, the (Test/ Procedure) is necessary to (Describe Why Necessary). Failure to perform the (Test Procedure) could result in the following problems:
(Describe Problem)
For these reasons, I urge you to reconsider your denial of payment authorization for the procedure I have prescribed. Enclosed are pertinent medical records supporting my recommendation.
By copy of this letter to (Patient’s Name), in my best medical judgment, I suggest that he/she obtain the (Test/Procedure), despite your denying payment authorization.
Yours truly,
(Your Name)
cc: (Patient’s Name)
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