Customer Service Department:
hereby, request that [name of medical group OR health plan] cover a bill I received for
[service, treatment OR procedure]. The service was provided on [date] by [name of provider
(doctor, lab, hospital, other)] to address [medical problem]. The bill I received
is for [amount] and must be paid by [date]. Since this bill should be covered by my
[medical group/health plan], therefore, I called the concerned [medical group/health plan]
on [date(s)], and spoke with [name of representative] concerning the bill, but the problem
has not yet been resolved.
would like to state the reasons as why this bill should be paid by [name of medical
group/health plan], namely:
- [name of
service] is a covered service under my health plan coverage terms;
- a referral
for [service, treatment/procedure] was provided by my primary care physician;
treatment OR procedure] was performed by my primary care physician;
treatment OR procedure] was performed by a specialist to whom I was referred by my primary
services were medically necessary;
- there are
no coverage exclusions or limitations of [service, treatment OR procedure], or that apply
to my case;
- I have met
all of my co-payment or deductible obligations under the health plans coverage
- I could
not get prior authorization before receiving [service, treatment/procedure] because my
health care problem was an emergency. I called my [primary care physician, health
plan/medical group] as soon as I could after receiving the [service, treatment/procedure],
as required by my health plan.
would like to emphasize that the [medical group/health plans] failure to pay the
bill violates [national/state] law which requires [applicable legal requirement]. I am
also attaching documentation supporting your responsibility for the bill.
in writing about the actions you will take regarding this request.
you for your prompt attention to this matter.