How To Create An Effective Appeal Letter Template For Medical Necessity?
Healthcare organisations like hospitals and clinics already have their hands full with numerous internal operations. The last thing a healthcare organisation wants is to spend hours or weeks sending appeal letters to their patient’s insurers.
But the truth is that there is no avoiding it. The best way around this problem is with an appeal letter template for medical necessity and automation. Here, we discuss how you can create an effective template for your medical appeal letters and send them efficiently using automation.
What Is A Medical/Insurance Appeal Letter?
A medical or insurance appeal letter is an appeal letter to a healthcare insurance provider to review its medical claim denial to a patient. Healthcare organisations like hospitals can send the appeal letter on behalf of their patients.
Although patients can send the medical appeal letter by themselves, it is often more practical for the hospitals to send it. Sending the appeal letter on behalf of their patients enables the hospitals to save significant time and speed up their medical payments.
There are several reasons why an insurer may deny the medical claim of a patient. Your healthcare organisation can only help with some claim denials. But in many cases, the hospitals can quickly get approval for the claim by sending an insurance appeal letter and supporting documents.
What Are The Common Reasons For Medical Claim Denial?
The first step in creating an appeal letter template for medical necessity is to find the reason for denying the claim. According to the General Insurance Code of Practice, the healthcare insurer must provide a legitimate reason for denying a claim.
Usually, the insurer sends a letter to the policyholder detailing their decision to deny a claim. Closely examine this letter and verify the details before sending the medical appeal letter to insurers.
Some common reasons for health insurance claim denial for your patients can include the following.
#1 Treatment Not Covered Under Insurance
Insurance companies can often deny your patient’s medical claims if the treatment is not covered under their insurance plan. There are several types of healthcare policy packages, and not all of them offer the same benefits. You must read the terms and conditions before sending the medical appeal letter to ensure that the patient’s claim is eligible.
It is best not to assume that a medical insurance policy will automatically cover any medical treatment. Ideally, you must discuss this with your patients at an early stage to avoid having to send an insurance appeal letter. For instance, most insurance providers do not cover cosmetic procedures under their policy. In such cases, the patient can not make a medical claim, and sending an appeal letter won’t help them.
Most healthcare policies have some form of exclusions, exceptions, or restrictions to the services and benefits they provide. You must have a general idea of these policy exclusions to send an insurance appeal letter for your patients.
#2 Treatments From Non-Participating Hospitals
The health insurance company may deny a claim if your hospital doesn’t have an agreement with it. Ideally, you must check if the patient’s healthcare provider collaborates with your hospital long before sending the medical appeal letter.
However, there may be some misunderstanding, and yours is a participating hospital. In that case, you can send an insurance appeal letter to the insurer clarifying the same. As the party that collaborates with the insurer, it’s easier for you to sort out such misunderstandings by sending the letter on your patient’s behalf.
#3 Benefit Cap
As you know, some healthcare policies may have a benefit for specific insurance services. It means the patient or their healthcare policy has a limit on the benefit amount they can obtain from the insurer each year. Usually, the insurer highlights the benefit cap in their policy terms. Check if a benefit cap exists for the patient’s policy and verify it before sending the medical appeal letter to the insurer.
One thing you must note about the benefit cap is that it can be different from one policy provider to another. Sometimes, the annual limit or benefit cap is applicable per calendar year, and sometimes it can be the financial year. Some insurers calculate a yearly limit of 12 months from taking the policy. It is best to check the benefit cap before sending an insurance appeal letter.
#4 Waiting Period
In most medical claims, the patient can only access the full benefits of their policy after a specific time of taking it. Generally, there is a waiting period before the patient can reap the full benefit of their healthcare policy. Check the Date your patients took the healthcare policy before sending the medical appeal letter to insurers.
The following table shows the general waiting period for healthcare policies for different health conditions of the patient.
| Waiting Period In Months | Type Of Healthcare Insurance |
| 12 | Pre-existing disease/health condition |
| 12 | Pregnancy |
| 2 | Psychiatric treatments |
| 2 | Rehabilitation treatments |
| 2 | Generic healthcare |
As you can see, some of these waiting periods are extensively long. It is worth noting the insurance waiting period to avoid payment delays over a technicality. But, it is also worth noting that insurers may waive the waiting periods. An ideal medical claim letter may help with it, especially when a hospital sends it on behalf of the patient.
Note: The patient only has to repeat their waiting period when switching their policy if upgrading to a higher-level policy.
#5 Benefit Limitation Period
Some medical treatments or procedures, such as joint replacements, may have an additional waiting period. The extra waiting period for such medical treatments is a benefit limitation. It is a concept you should familiarise yourself with to send an insurance appeal letter to insurers effectively.
The challenges posed by the benefit limitation period are the same as the regular waiting period for policies. In most cases sending a medical appeal letter can not help in approving the patient’s claim. Hence, you must keep an eye open for such treatments and their medical claims. Ideally, you must check the insurance situation early to avoid any unnecessary haggling.
#6 Expiry Date
One reason that the insurer may show for denying a policy claim is the policy’s expiration date. The insurance provider may refuse a claim if you or the patient are too late to file a claim. Most insurance providers do not accept claims if they are more than two years old. Healthcare payments at hospitals are almost always on time. In this case, the patient will likely send the medical appeal letter to the insurer.
#7 Paperwork Error
Insurance paperwork can be a nightmare for patients. There is a good chance that patients accidentally miss a crucial paper for the policy claim. It is also possible that the doctor accidentally submitted the wrong documents. You can ensure that the same mistake only happens once by sending the insurance appeal letter on the patient’s behalf.
Paperwork errors are one of the most common reasons for healthcare claim denials. Even minor mistakes could lead to claim denial. For example, the insurer may deny the claim because you or the patient sent the wrong receipt. Even incorrectly filling out a form could lead to claim denial. The good news is that you can quickly send the medical appeal letter using automation.
What Are The Things To Include In Your Medical Appeal Letter?
To create an effective medical appeal letter for your business, you must first understand the details you should include. The trick is to create a concise template for different situations you may need to send an appeal letter.
Once you create the template, printing or writing an appeal letter to insurers becomes significantly easier. Conceiving an appeal letter template for medical necessity can help you even if you are still using a manual process. Moreover, it can automate the mailing process much more efficiently and faster.
The Major elements or pieces of information you must include in the insurance appeal letter are as follows.
Patient Details
The medical appeal letter you sent to the insurer is not for your healthcare organisation. You are sending it on behalf of your patient. Technically the claim issue is between the patient and their insurer. The healthcare organisation is only the middleman in the interaction.
Ensure to include all the patient details necessary for the insurance provider to identify the patient and their policy. It means including patient information in the insurance appeal letter, such as the following.
- Patient name.
- Policyholder name.
- Policy number.
Contact Information
The medical appeal letter you send to insurance providers must also contain the necessary contact information. Suppose the patient is sending the appeal letter themselves. In that case, they must only include the contact details of the patient and the policyholder.
But suppose you are sending the medical appeal letter on the patient’s behalf. In that case, you must include the relevant contact information of your healthcare organisation. Double-check the contact details before you send the letter, as any mistake could delay the payment processing for your hospital.
Details Of The Denial Letter
Make sure to include the details of the denial letter in the insurance appeal letter you send to the insurer. Try to include all essential information about the denial letter, such as the Date of the claim denial letter and the reason cited for the claim denial. It would be best to mention other specifics of the claim denial, such as the medical procedure for which the insurer denied the claim.
Details Of The Medical Service Provider
The medical appeal letter should also include the details of the patient’s attending physician or medical service provider. It should be relatively easy to provide these details in the appeal letter when you send it on behalf of the patient.
The process becomes even simpler by using a direct mail automation solution like PostGrid. With a tool like PostGrid, you can use an appeal letter template for medical necessity to efficiently send the letters. PostGrid’s tool enables you to send bulk mail as long as you have the appropriate templates.
Reasons For Approving The Claim
The goal of sending an insurance appeal letter on behalf of your patients is to approve their claims and speed up your payment. Therefore, you must include the necessary details explaining why the policy should cover a claim. It is a crucial aspect of the letter, and you must also attach any supporting documents as proof with the letter.
Appeal Letter Template For Medical Necessity
Above, we discussed when your healthcare organisation must a medical appeal letter and the details to include in the letter. However, you may still have questions about writing an appeal letter from scratch.
Here is an appeal letter template for the medical necessity that you can use as a reference for creating an appeal letter for your hospital.
[Date]
[Name]
[Insurance Company Name]
[Address]
[City, State, and ZIP Code]
Re: [patient’s Name]
[Insurance Coverage Type]
[Group/Policy Number]
Dear [Appeal analyst’s Name]
I am writing to request a reconsideration of the claim denial from [healthcare plan and policy number] prescribed to [patient’s Name] for [Name of healthcare procedure/treatment/service].
Our understanding is that [Name of insurer] is denying the medical claim to our patient because of “[reason cited in the claim denial letter].” It is medically necessary for [patient’s Name] to receive [Name of healthcare procedure/treatment/service] for their present health condition.
The [Name of healthcare procedure/treatment/service] is covered under the patient’s health plan benefit. According to the Evidence of Coverage, [healthcare plan and policy number] covers all necessary healthcare services unless explicitly excluded.
I want to reiterate that [patient’s Name] ‘s healthcare team unanimously agrees that the [Name of healthcare procedure/treatment/service] is medically necessary. And in contrary to your denial letter, [Name of healthcare procedure/treatment/service] is a covered medical service as it is not expressly excluded in the coverage agreement. [attach the necessary sections of the coverage clause]
[Describe the patient’s medical condition and explain how the medical procedure/treatment/service can benefit them. You can mention what would happen if the patient does not receive the medical procedure/treatment/service.]
[Establish there is no appropriate healthcare service within the network if the medical treatment is out-of-network.]
[If you think a precedent could disqualify the patient from accessing plan benefits, request to provide them as extra-contractual benefits. Request for payment for the medical service/procedure/treatment out of the catastrophic payment pool of the health plan]
[Attach all necessary documents, including a letter from the attending physician of the patient]
Thank you for your prompt attention to this matter.
Sincerely,
[Your Name]
[Signature]
How To Send A Medical Appeal Letter On Behalf Of Your Patients?
At this point, you know how to write an effective medical appeal letter. Now, let’s discuss the best way to send it. The thing about healthcare organisations like hospitals sending the appeal letter on behalf of their patients is its quantity.
Healthcare organisations may have to send many letters as they deal with numerous patients and their medical claims. It means bulk mailing the insurance appeal letter to different insurance providers. Here is how you can effectively send your letter for appealing medical claims.
Utilise An Appeal Letter Template For Medical Necessity
One of the most efficient ways to send medical claim appeal letters for your patients is to use an appeal letter template for medical necessity. The template can make the process significantly easier for a manual or automated process.
However, even with an appeal letter template for medical necessity, it can still be challenging to prepare and send the letter in large numbers. It is always best to utilise automation to send your healthcare letters, as it can save you much time.
Use PostGrid’s Direct Mail Automation Tool
The best and most efficient way to send you a medical claim letter is with the help of tools like PostGrid. Advanced direct mail automation software like PostGrid can quickly generate personalised healthcare letters for your medical organisation. It can use the appeal letter template for medical necessity to print your appeal letters.
PostGrid offers a platform and a dedicated direct mail API to bulk mail healthcare letters. Using the web interface for bulk mailing is significantly more convenient than you think. You can sign up on PostGrid’s website and use its intuitive dashboard for sending bulk mail, including medical appeal letters and other healthcare documents.
PostGrid offers a free template gallery and editor to create medical letters or postcards for your organisation. Moreover, you can use PostGrid’s system to send all healthcare letters, including an insurance appeal letter or execute direct mail marketing campaigns. The tools also offer better tracking capability to manage your marketing and communication efforts.
Do you want to learn how to use an appeal letter template for medical necessity to send an appeal letter quickly? Talk to our experts to set up a free demo from PostGrid.
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