Prior authorization 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}} dated {{DENIAL_DATE}}. The stated reason was that prior authorization was not obtained (or was denied).

The denial should be reversed for the following reasons:

1. {{PA_FACT_PATTERN}} — either (a) prior authorization was submitted on {{PA_SUBMISSION_DATE}} (reference #{{PA_REFERENCE}}), (b) the plan document does not require prior authorization for this service, or (c) the service was rendered under emergent circumstances protected by federal and plan rules.

2. My treating physician has documented that the service was clinically indicated and delay would have caused harm.

3. Under 29 CFR 2560.503-1(h)(2)(iii) I request the complete claim file, including the specific prior authorization policy applied.

Please overturn this denial and process the claim for payment.

Sincerely,
{{MEMBER_NAME}}

Key points before you send it

• Attach documentation that PA was submitted, or that the service was urgent / emergent and PA was not required.
• Point to the exact plan document language on prior authorization exceptions.