Practice address
PO BOX 123
Kenneth City FL1234
Phone#123-456-789
_______________________________________________________________________
05/10/2010
Careplus
Attn: Medical Records Department
4925, Independence Parkway Suite 300
Tampa, FL, 33634
Re: Appeal of Medical Claim
Patient Name:
Health Insurer Identification Number: 9958002012111
Claim Number: 911204441611
Call Reference Number: 91111365797111
Service Date: 10/13/2009
Dear Sir/Madam:
We are appealing your decision and requesting reconsideration of the attached claim that was denied on 12/08/2009 as "Global payment made to Facility for this service. Seek reimbursement for professional fees from facility appropriately."
We feel these charges should be allowed for the following reason(s):
• Dr.X is the only Physician who interpreted the service (Professional component only) performed at Outpatient Hospital on 10/13/2009. Hence Dr.X is due and eligible to get paid for the professional
services that he had rendered.
• Hospital has billed Careplus for a global procedure in error. This facility only performed the technical component.
Now we are requesting you to reconsider our claim, reverse the payment of professional component from the other group and reimburse Dr. for the same.
When we had a discussion with the Careplus customer service, the representative advised us to file an appeal with supporting medical documents. Herewith I have attached the Claim form, Dr. X Intrepretation document and Careplus EOB.
Thank you for reviewing and reversing this claim denial. If you require any additional information, please contact me at 407-123-4567 between the hours of 8:00 a.m-5:00 p.m.
Sincerely,
(Account Receivable – Reimbursement Specialist)
PO BOX 123
Kenneth City FL1234
Phone#123-456-789
_______________________________________________________________________
05/10/2010
Careplus
Attn: Medical Records Department
4925, Independence Parkway Suite 300
Tampa, FL, 33634
Re: Appeal of Medical Claim
Patient Name:
Health Insurer Identification Number: 9958002012111
Claim Number: 911204441611
Call Reference Number: 91111365797111
Service Date: 10/13/2009
Dear Sir/Madam:
We are appealing your decision and requesting reconsideration of the attached claim that was denied on 12/08/2009 as "Global payment made to Facility for this service. Seek reimbursement for professional fees from facility appropriately."
We feel these charges should be allowed for the following reason(s):
• Dr.X is the only Physician who interpreted the service (Professional component only) performed at Outpatient Hospital on 10/13/2009. Hence Dr.X is due and eligible to get paid for the professional
services that he had rendered.
• Hospital has billed Careplus for a global procedure in error. This facility only performed the technical component.
Now we are requesting you to reconsider our claim, reverse the payment of professional component from the other group and reimburse Dr. for the same.
When we had a discussion with the Careplus customer service, the representative advised us to file an appeal with supporting medical documents. Herewith I have attached the Claim form, Dr. X Intrepretation document and Careplus EOB.
Thank you for reviewing and reversing this claim denial. If you require any additional information, please contact me at 407-123-4567 between the hours of 8:00 a.m-5:00 p.m.
Sincerely,
(Account Receivable – Reimbursement Specialist)
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