Medicare is the insurance the U.S. government provides for individuals who are aged 65 and older. Over the years Medicare reimbursement rules have become increasingly stringent. Physicians, hospitals and insurance billers have to be extremely careful to get pre-approval from Medicare for procedures and use all of the proper codes when billing for those procedures. When Medicare refuses to pay a claim, the patient or the provider can write a Medicare appeal letter.
Format and Content
The Medicare appeal letter format should include the beneficiary’s name, their Medicare health insurance number, the claim number and specific item or service that is associated with the appeal, dates of service, name and location of the facility where the service was performed and the patient’s signature. It is a good idea to be prepared to provide medical records to the Medicare representative who is researching your appeal as well as a letter from the physician who performed the procedure. In addition, find out the name of the person to whom the letter should be addressed as well as the proper department and address.
Coding is very important in the submission of Medicare claims and incorrect codes can send the process into a tailspin. This Medicare appeal letter sample is from a patient whose provider inadvertently left a code off of her bill causing the claim to be denied. She has obtained a corrected bill from the provider with the missing code added and is appealing to Medicare to pay the corrected claim.
943 West 87th Street
New York City, NY 11111
Medicare ID 123456789
Date of birth: 11-11-1945
Date of Service: August 16, 2013
Mr. Anthony P. Haynes
Medicare Appeals Representative
P.O. Box 22222
New York City, NY 11111
September 16, 2013
RE: Appeal of Denial on Claim 987654321
Dear Mr. Haynes,
I am writing to appeal the denial of my claim number 987654321 for the date of service of August 16, 2013. This was for surgery that was performed on me at ABC Medical Center to repair the fracture to my left leg which I suffered when I tripped and fell down the basement stairs in my home.
It is my understanding that the claim was denied and the hospital was not paid for the services rendered to me to repair my broken leg. Furthermore, I understand that the reason for the denial was that a modifier code indicating which one of my legs, right or left, was fractured. Apparently the insurance biller at the hospital left off the modifier code “L” to specify that the surgery was performed on my left leg.
A supervisor in the hospital billing department has corrected the claim to include the modifier code of ”L” indicating the specific leg that was treated. The corrected claim is attached and I respectfully ask you to reprocess my hospital bill and pay the provider for the services that were rendered to me and for which I have Medicare coverage. Thank you for your consideration.
Sarah F. Greene