Your denials have a solution. Templates, Resolution Kits, and more.

Practice and/or Provider Information

On practice letterhead start with:

• Provider Name and Credentials
• Practice or Facility Name, NPI and Tax ID
• Address
• Contact Information
• Appeal Date

Payer and Patient Information

Accurately provide the following:

• Payer Name
• The correct appeals or resolution department*
• Payer Address*
• Contact Information
• Patient Name
• Member ID/Policy ID
• Patient's date of birth

*check the payer's website, or look for the correct department on the EOB

Claim Details and Appeal Purpose

• Procedure code(s) denied/being appealed
• Denial/explanation code(s) with description
• Payer Claim/ICN number
• Date of Service

Always open with a clear, concise and direct statement that addresses the reason for the appeal. Example: "We are writing to formally appeal the denial of coverage for..."

Detailed Argument

This is the core of your appeal. State plainly why the denial is wrong, whether the argument is clinical (medical necessity, distinct service), policy-based (payer, or LCD/NCD, for example), regulation or guideline based (AMA, CMS, etc.) or contractual. State why the service should be covered based on argument (e.g., if policy based, be prepared to indicate what policy applies, and why the services meets the policy criteria). Use authoritative sources, such as AMA, LCD, NCD, CMS, etc. Cite your sources.

Supporting Documentation & Evidence

• Operative notes, progress notes, or encounter summaries
• Specialist consult notes/other clinical evidence
• Diagnostic imaging, labs, or test results
• Referral or prior authorization (if obtained)
• Copies of payer policy showing coverage criteria
• Reimbursement advice/denial notice
• Literature/Guidelines/other polices supporting medical necessity from authoritative sources

Explicit Request for Reconsideration

Tell the payer exactly what you want. Such as: "Reprocess claim [number] with allowed amount reflecting [rate]" or "Overturn the denial and pay the claim at the contracted rate." Ambiguity gives the payer permission to close the file without acting.

Signature and Credentials

Provider or authorized representative's name, title, credentials, including the NPI. For clinical or necessity appeals, a clinician's signature carries the most weight. For coding denials, having a certified coder listed as the contact person can help minimize friction in those situations. A named, reachable signer always makes follow-up easier.