Provider Appeal Letter Sample for Prior Authorization, Medical Necessity, and Untimely Filing Denials

Just one in 10 payer denials are appealed according to a Kaiser Family Foundation analysis. 

The American Medical Association asks, “Why aren’t there more?” 

The statistic is particularly concerning when one considers that the overwhelming majority of appeals are ultimately overturned — 54% of private payer denials according to a study of 516 hospitals and 83.2% according to the KFF analysis. That’s a lot of revenue left on the table. 

There’s money in appeals, but too often, providers just don’t have the staff to get the appeals written and submitted. In fact, in a recent AMA prior authorization survey,  48% responded that insufficient practice staff time or resources is their biggest impediment.

When you need to do anything to get those appeals out the door, using a provider appeal letter sample makes sense. 

Here, you’ll find provider appeal letters for prior authorization, medical necessity, and untimely filing denials. Use them to get your denial overturn rate up and become the organization’s golden goose (for a while, anyway). 

What is a provider appeal letter?

A provider appeal letter is a formal written request from a healthcare provider to an insurance company, asking the insurer to reconsider and overturn a previously denied claim or prior authorization request. This letter typically outlines the reasons why the provider believes the denial was incorrect, emphasizing the medical necessity of the service or medication for the patient. It is usually accompanied by supporting documentation, such as relevant medical records, clinical guidelines, and letters of medical necessity, to strengthen the argument for coverage and payment.

Provider appeal letter general guidelines

When drafting and submitting a provider appeal letter, adhering to general guidelines improves the chances of approval. These best practices ensure that the appeal is properly received, considered, and tracked by the insurance company.

• Review payer guidelines: Always refer to the specific insurance plan’s appeals guidelines, as they may outline a particular process or require specific forms. Find payer guidelines on Availity, payer portals, payer newsletters, and even mailed updates. Don’t let a recent change on their part prompt a second denial. 
• Timeliness: Submit the appeal within the timeframe specified by the insurance company.
• Tracking: Send the letter via certified mail with a return receipt requested, or by fax with a confirmation of successful transmission, to have proof of submission.
• Record Keeping: Keep copies of the appeal letter, all submitted documents, and any correspondence with the insurance company.
• Confirmation: Expect an official notice within 7-10 days confirming receipt of your appeal. If not received, follow up with the insurance company. The squeaky wheel gets the grease, of course. 

Below are sample letters for three common payer denials. Fill specific information in between the brackets.

Prior authorization denial provider appeal letter sample

Get all the patient details in front of you, along with the initial denial letter. You can reference our CARC and RARC codes guide here to construct your argument. 

[Your Practice/Clinic Letterhead]

[Date]

[Insurance Company Name]
[Appeals and Grievances Department or Prior Authorization/Appeals Department]
[Insurance Company Address]
[City, State, Zip Code]

RE: Appeal of Prior Authorization Denial
Patient Name: [Patient's Full Name]
Policy ID Number: [Patient's Insurance Policy Number]
Group Number (if applicable): [Patient's Insurance Group Number]
Denial Reference/Case ID Number: [Reference Number from Denial Letter]
Patient Date of Birth: [Patient's Date of Birth]
Date of Service (if applicable, or anticipated date if pre-service): [Date of Service]
Service/Medication Denied: [Name of Service/Procedure/Medication and CPT/HCPCS Code, if applicable]

Dear [Contact Person or "To Whom It May Concern" at Insurance Company Name]:

I am writing on behalf of my patient, [Patient's Full Name], to appeal the denial of prior authorization for [Service/Medication Name], as communicated in your letter dated [Date of Denial Letter]. The stated reason for denial was: [Quote the exact reason for denial from the letter].

We request that [Insurance Company Name] reconsider this decision. The [Service/Medication Name] is medically necessary and clinically appropriate for this patient's condition.

Patient Medical History and Rationale for Treatment:
[Patient's Full Name] was diagnosed with [Patient's Diagnosis and ICD-10 Code, if applicable] on [Date of Diagnosis].

[Briefly describe the patient's relevant medical history, including symptoms, functional limitations, and previous treatments tried and their outcomes. Explain why the denied service/medication is the most appropriate next step in their care.] For example:

• "[Patient Name] has experienced [specific symptoms, e.g., debilitating pain, significant impact on daily life, etc.]."
• "Previous treatments, including [list previous treatments/medications], have been [ineffective/resulted in intolerable side effects/are contraindicated]."
• "Without [Service/Medication Name], the patient's likely prognosis includes [describe negative outcomes, e.g., worsening of condition, continued functional impairment]."

Supporting Clinical Evidence:
The decision to prescribe/recommend [Service/Medication Name] is based on [mention current clinical guidelines, peer-reviewed studies, or standard of care that supports this treatment for the patient's condition]. [Cite specific guidelines or studies if possible]. For instance:

• "The American College of [Relevant Specialty] recommends [Service/Medication Name] for patients with [Condition] under these circumstances."
• "Published research, such as [Study Title/Journal], demonstrates the efficacy and safety of [Service/Medication Name] for this condition."

[If applicable, explain how the patient meets the payer's own medical policy criteria for the requested service/medication, or why an exception is warranted.]

The clinical information provided supports the medical necessity of [Service/Medication Name] for [Patient's Full Name]. We believe that coverage of this [service/medication] is justified under the terms of the patient's policy.

Enclosed with this letter, please find the following supporting documentation:

• Copy of the prior authorization denial letter
• Relevant excerpts from the patient's medical record (e.g., chart notes, test results)
• A letter of medical necessity (if separate from this appeal letter)
• Relevant clinical practice guidelines or published medical literature
• [Any other supporting documents, e.g., prescribing information for a medication]

Please reconsider this adverse decision and approve coverage for [Service/Medication Name] for [Patient's Full Name]. Prompt approval is crucial for the patient's health and well-being.

We appreciate your prompt attention to this appeal and look forward to your reconsideration. If you require any additional information, please do not hesitate to contact me at [Your Phone Number] or [Your Email Address].

Sincerely,

[Your Name, Credentials (e.g., MD, DO, NP)]
[Your NPI Number]
[Practice/Clinic Name]
[Practice/Clinic Address]
[Practice/Clinic Phone Number]
[Practice/Clinic Fax Number]

If this one is too long, consider this prior authorization denial appeal letter from Patient Advocate Organization. 

Medical necessity provider appeal letter sample

When a claim is denied due to lack of medical necessity, the insurance company has determined that the service or procedure was not essential for the patient's diagnosis or treatment according to their policies. Appealing these denials requires a well-structured letter that clearly "makes the case" for coverage by demonstrating why the provided care was, in fact, medically necessary for that specific patient 

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[Your Practice/Clinic Official Letterhead and Logo] 

 [Appeal Date]

[Provider Name]
[Provider Address]
[Provider Fax Number or Phone Number]

Attention To: [Appeals Department/Specific Reviewer, Title, Department]
[Insurance Company Name]
[Insurance Company Address]

RE: Appeal of Medical Necessity Denial
Patient Name: [Member/Patient Name]
Member’s Insurance ID: [Member’s Insurance ID]
Claim Number: [Claim Number]
Date(s) of Service: [Dates of Service]

Encounter or Account Number: [Encounter or Account Number]
Disputed Dollar Amount: $[Disputed Dollar Amount]
Authorization Number (if applicable): [Authorization Number]

Dear [Contact Person or "To Whom It May Concern"]:

[Provider Name] submits this Appeal Level [1, 2, or 3, as applicable] and disputes [Payer Name]'s denial of the claim referenced above, which was denied on [Date of Denial] due to [Quote the exact reason for denial from the remittance advice, e.g., "services not deemed medically necessary"]. 

We assert that the medical services provided were medically necessary for the diagnosis and/or treatment of [Patient Name]'s condition.

Patient's Condition and Justification for Services:
The patient, [Patient Name], presented with [describe patient's symptoms and initial presentation]. After a thorough evaluation, [he/she/they] was diagnosed with [Diagnosis Code and Code Description]. The medical services provided on [Date(s) of Service], specifically [list denied CPT/HCPCS codes and describe the service/procedure], were critical for [explain the specific benefit to the patient, e.g., diagnosing the condition, managing symptoms, preventing deterioration, etc.].

The patient's medical history includes [briefly detail relevant medical history, comorbidities, prior treatments attempted and their outcomes, and any extenuating circumstances that made this service necessary for this specific patient]. The severity of the patient's situation was [describe severity] and is clearly documented in the enclosed medical records. Providing this treatment [may have avoided more expensive treatment in the future, or was necessary because no other viable in-network options were available, etc.].

Clinical Support for Medical Necessity:
The decision to provide [Service/Procedure Name] is supported by [cite relevant ICD-10-CM Official Guidelines for Coding and Reporting, Coding Clinics, established clinical practice guidelines from recognized medical societies (e.g., ACFAS, AMA), peer-reviewed scientific literature, or the payer's own medical policies if applicable]. [For example: "As per the guidelines from [Name of Society/Organization], the rendered services are considered standard care for [Patient's Condition] with [Specific Patient Characteristics]."] We have enclosed copies of [mention specific literature or guidelines] for your review.

We request that [Payer Name] reconsider this denial and approve payment for these medically necessary services. We also request a peer-to-peer review of this claim, as [Payer Name] has not provided proof that a licensed medical professional with appropriate expertise conducted the initial review, as may be required by [cite your participating agreement or relevant federal/state regulations].

Enclosed Supporting Documentation:

• Copy of the remittance advice/denial notice
• Relevant excerpts from the patient's medical record (e.g., physician's notes, operative reports, progress notes, test results like labs/X-rays)
• [Relevant scientific literature or clinical practice guidelines supporting your position]
• [Other relevant reports or documentation]
  

We believe the enclosed documentation clearly demonstrates that the services rendered were medically necessary and appropriate for this patient's specific clinical circumstances. Please contact me if further information is required.

Sincerely,

[Appeal Author’s Name, and Credentials (e.g., MD, DO, Office Manager)]
[Provider’s NPI Number]
[Appeal Author’s Address, Phone, and Email]
[Provider’s URL Address (if applicable)

Sample Provider Appeal Letter for Untimely Filing Denial

When a claim is denied for "untimely filing," it means the insurance company asserts the claim was submitted after the specified deadline. Appealing these denials can be challenging, as payers often strictly adhere to their filing limits. However, an appeal may be successful if you can provide clear evidence that the claim was indeed submitted within the required timeframe, or if there were specific, documentable extenuating circumstances that caused a delay and warrant reconsideration

[Your Practice/Clinic Official Letterhead]

[Date]

[Insurance Company Name]
[Appeals Department or Claims Review Department]
[Insurance Company Address]
[City, State, Zip Code]

RE: Appeal of Untimely Filing Denial
Patient Name: [Patient's Full Name]
Policy ID Number: [Patient's Insurance Policy Number]
Claim Number: [Original Claim Number from Denial]
Date(s) of Service: [Date(s) of Service in Question]
Total Amount of Claim: $[Total Billed Amount]

Dear [Appeals Review Department or To Whom It May Concern]:

I am writing to formally appeal the denial of the above-referenced claim, which was denied on [Date of Denial Notice] with the reason stated as "failure to meet timely filing requirements". We contend that this claim was submitted by the timely filing period outlined in our contractual agreement and/or your payer guidelines.

The services were rendered to [Patient's Full Name] on [Date(s) of Service]. Our records indicate that the claim was originally submitted on [Original Submission Date]. According to our agreement with [Insurance Company Name], the timely filing limit for claims is [State the timely filing limit, e.g., "90 days from the date of service" or "12 months from the date of service"]. Our submission on [Original Submission Date] was therefore within this required timeframe.

To support our assertion of timely submission, we have enclosed the following documentation:

• A copy of the original claim submission confirmation from our clearinghouse (or electronic payer portal), timestamped [Original Submission Date].
• A print screen from our billing system demonstrating the claim creation and transmission date.
• A copy of the denial notice (Explanation of Benefits/Remittance Advice).
• [If applicable, add: "A copy of the relevant section of our provider manual or contract with [Insurance Company Name] highlighting the timely filing deadline."]

We believe there may have been an error in the processing of this claim on your end or a misunderstanding regarding the submission date. We respectfully request a thorough review of the enclosed documentation and a reconsideration of this denial.

[Optional: Include this paragraph if there were specific, verifiable extenuating circumstances that caused a delay, and you are appealing for an exception, rather than asserting it was filed on time. For example:]

• "[Alternatively, if a delay occurred: We acknowledge the claim was submitted on [Actual Late Submission Date]. However, this delay was due to [clearly and concisely explain the specific, verifiable reason for the delay, e.g., 'a system-wide outage at our clearinghouse from [start date] to [end date], documentation of which is attached,' or 'delayed confirmation of the patient's active coverage for the date of service, despite our diligent efforts to verify, with supporting communication logs attached']. We request an exception to the timely filing limit in this specific instance due to these unavoidable circumstances." ]

We are confident that upon review, you will find that this claim either met the timely filing requirements or warrants an exception. We request prompt reprocessing and payment of this claim.

Please do not hesitate to contact our office at [Your Phone Number] or [Your Email Address] if any further information is required.

Sincerely,

[Your Name, Credentials (e.g., MD, Office Manager)]
[Your NPI Number, if applicable]
[Practice/Clinic Name]
[Practice/Clinic Phone Number]

Enclosures:

• Copy of Claim Submission Confirmation
• Billing System Record Screenshot
• Denial Notice (EOB/RA)
• [Other relevant documents as mentioned above]

Streamline and strengthen appeals with claims and denial management software

Facing a revenue cycle staffing shortage, healthcare is turning to AI-driven software for healthcare claims management. Claims management, a traditional revenue cycle bottleneck, now benefits from advanced technology. With nearly universal electronic claims submission, modern software leverages AI and automation for streamlined cross-payer processing, audit responses, appeal submissions, ADR tracking, and even AI-generated appeal letters. (Doximity, a telemedicine platform, recently released a generative AI tool that can draft appeal letters.)

Today, the CAQH Index reveals that 98% of providers use fully electronic claims submission processes.  

Take a quick, self-guided tour through a powerful denial and claims management system:

MD Clarity’s RevFind fuels your appeals success

Today, it takes specialized denial management software driven by AI and automation to make the denial appeals process cost-effective. It’s a necessity for improving revenue, ensuring patients receive the care they need, and reducing administrative burdens. By proactively identifying potential denials, automating error detection and workflows, and providing deep analytics for root cause analysis, modern denial management software transforms a reactive, labor-intensive process into a strategic, efficient revenue optimization engine.

MD Clarity’s RevFind claims and denials management features strengthen your denial management strategy. While it excels at contract management by digitizing and analyzing payer agreements to uncover underpayments, its capabilities extend directly into preventing and managing denials as well. RevFind targets major causes of front-end denials like eligibility and registration issues. Its robust reporting interface allows for in-depth analysis of denial trends across multiple dimensions, facilitating root cause identification to prevent future denials. Furthermore, RevFind’s workqueue feature streamlines the appeals process by automatically distributing denied claims to the appropriate team members, enhancing your team's ability to optimize cash flow and secure reimbursements. Investing in denial management software is essential for healthcare providers aiming to achieve financial stability and operational excellence in today's complex landscape.

Request a demo today to discover how RevFind can get you appealing more denials and sweeping in that earned revenue. 

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