Email appeal template
RE: Appeal of Comparison of Allowables for [ENTER COMPANY / PROVIDERS NAME]
[Your Company Information]
[Insurance Name]
[Contracted Plan Name / Fee schedule]
[Date of Service Timeframe]
[Total Variance Amount]
[Month Day, Year]
To Whom It May Concern,
After a thorough review of the terms agreed to in our contract, it has come to our attention that we have been underpaid. Our provider agreement with [INSURANCE NAME] states that we should be paid [ENTER TERMS] for [ENTER HERE THE FEE SCHEDULE (PLAN)], we are showing that the referenced claims were paid at [ENTER WHAT THE CLAIMS WERE PAID AT]. There is a total of [TOTAL NUMBER OF UNDERPAID LINES AND OR CLAIMS] and an outstanding variance amount of [THE VARIANCE TOTAL AMOUNT]. Attached is the detailed breakdown and support of the information we found.
This email and the attached documentation serve as notice of our objection to these payments and request for reprocessing. After reviewing all the information please get back to us with an expected date for reprocessing. If no further payment is to be made respond to this email with a copy of an applicable policy, referenced documentation in the provider manual, or explanation of how the obligated contractual terms were satisfied.
Sincerely,
[Your name]
Letter appeal template
Use the following template for letter-based appeals. Don't forget to print out the needed CSV from Rivet.
[Your Company Information]
[Insurance Name]
[Contracted Plan Name / Fee schedule]
[Date of Service Timeframe]
[Total Variance Amount]
RE: Appeal of Comparison of Allowables for [ENTER COMPANY / PROVIDERS NAME]
[Month Day, Year]
To Whom It May Concern,
After a thorough review of the terms agreed to in our contract, it has come to our attention that we have been underpaid. Our provider agreement with [INSURANCE NAME] states that we should be paid [ENTER TERMS] for [ENTER HERE THE FEE SCHEDULE (PLAN)], we are showing that the referenced claims were paid at [ENTER WHAT THE CLAIMS WERE PAID AT]. There is a total of [TOTAL NUMBER OF UNDERPAID LINES AND OR CLAIMS] and an outstanding variance amount of [THE VARIANCE TOTAL AMOUNT]. Attached is the detailed breakdown and support of the information we found.
This letter and the attached documentation serve as notice of our objection to these payments and request for reprocessing. After reviewing all the information please get back to us with an expected date for reprocessing. If no further payment is to be made respond to this letter with a copy of an applicable policy, referenced documentation in the provider manual, or explanation of how the obligated contractual terms were satisfied.
Sincerely,
[Your name]