To: _______________

Provider Appeals Dept.

__________________

__________________

Insured/Plan Member: ____________________

I.D. # ____________________

Group # _________________

Patient __________________

Claim # _________________

We are appealing your decision and request reconsideration of the attached claim for which you denied on ______________________.  We feel these charges should be allowed for the following reason(s);

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Thank you for reviewing this claim. Please call if you have any questions at ___________.

Sincerely,