Out-of-network denial appeal letter

Template

{{MEMBER_NAME}}
{{MEMBER_ADDRESS}}
{{MEMBER_PHONE}}
Member ID: {{MEMBER_ID}}
Claim / Reference #: {{CLAIM_NUMBER}}
Date of Service: {{DATE_OF_SERVICE}}
Date of Denial Notice: {{DENIAL_DATE}}

{{INSURER_NAME}}
Appeals and Grievances Department
{{INSURER_APPEAL_ADDRESS}}

Re: Formal Internal Appeal — {{CLAIM_NUMBER}}

I am appealing the denial of {{SERVICE_OR_DRUG}} on the basis that the provider was out-of-network.

1. {{OON_FACT_PATTERN}} — either (a) the service was emergency care protected under the No Surprises Act and must be paid at in-network cost-sharing, (b) no in-network provider with the required specialty was reasonably available within {{DISTANCE_OR_WAIT}}, or (c) I had established continuity of care with this provider prior to a network change.

2. Attached is documentation supporting the fact pattern above, including the emergency ED note / referral / continuity-of-care record.

Please reprocess this claim at the in-network benefit level under the No Surprises Act and/or the plan's network gap exception rules.

Sincerely,
{{MEMBER_NAME}}

Key points before you send it

• If the care was emergency, invoke No Surprises Act protections (in-network cost-sharing).
• If no in-network specialist was reasonably available, request a network gap / continuity-of-care exception.