Claims Appeals
Sample Insurance Co.
PO Box 000, Anywhere, ST 00000
Re: Appeal of Claim #[claim id], DOS [date of service], Member ID [member id]
To Whom It May Concern:
This appeal is submitted within the 180-day window afforded to group health plan claimants under 29 C.F.R. section 2560.503-1(h)(3)(i).
The Explanation of Benefits dated [EOB date] denied the claim citing bundling of CPT [code A] with CPT [code B] as duplicative same-day services. The two encounters were clinically distinct and separately documented.
Ground of appeal: bundling incorrect.
Applicable authority: 29 C.F.R. section 2560.503-1 (ERISA claims procedure, full and fair review).
I request reprocessing of both CPT codes as separately reimbursable per the plan's stated coding policy and full payment consistent with the Summary Plan Description.
Enclosures:
- Copy of the Explanation of Benefits
- Copy of the encounter note distinguishing the two services
Sincerely,
[appellant name]
[appellant address]
Not legal advice. Not medical advice. You are the appellant. Basis Appeals formatted this document from information you supplied and rule citations from public regulations. Questions: support@basis-works.example.