Filing an Informal Request for a Disputed Plan Payment Decision – Sample Letter

Re: Patient Name:
Insurance Carrier/ Health Plan/ IPA
Insurance ID Number:
Date of Service:
Billed Amount:
Payment Received:
Balance Due:

To Whom It May Concern:

I have received your [denial] [downcoding] [other] of a claim submitted for payment
concerning [treatment or
procedure]. Unfortunately, I do not understand why this action was taken and the law requires that I be provided the specific reasons to support the claim
[denial] [downcoding] [other].

California law requires that health care service plans and health insurers, upon rejecting a claim from a pharmacist, disclose the specific reasons why the claim was rejected. (Health & Safety Code §1399.55, Insurance Code §79601.)

Federal ERISA law similarly requires that you provide my patient on request the specific reasons for the adverse determination, written in plain language. The explanation must refer to the plan provisions on which the action is based, include a description of any additional information that is necessary and explain why this information is necessary, include an explanation of the
scientific or clinical judgment for any determination that the care was not medically necessary or was experimental or
investigational, applying the terms of the plan to my patient’s medical circumstances, and disclose any internal rule,
guideline, protocol or other similar criterion that was relied on in making this decision. I am acting as my patient’s authorized
representative for purposes of this dispute. (29 C.F.R. §2560.503-1(g)).

Because of the failure to explain why the claim was [rejected] [downcoded] [modified], I do not know whether I should
formally appeal your claim decision. It is far more efficient for everyone to have this information early on to understand whether an appeal is warranted. Consequently, I am asking for a clear explanation for the payment decision. If additional
information is needed for you to reconsider the claim, I will
submit that information.

Thank you for your attention to this matter.

Very truly yours,

[Pharmacist’s name]