Sample Letter To Request External Review Of Autism Assessment Or Treatment Denial printable pdf download

Sample Letter To Request External Review Of Autism Assessment Or Treatment Denial

Sample Letter to Request External Review of Autism Assessment or Treatment Denial – For Private Insurance

Your Name

Your Address

Date

Name and Address of the Health Plan’s Appeal Department

Re:

Name of Child:

Plan ID Number:

Claim Number:

Provider Name:

Date(s) of Service:

To Whom It May Concern:

I am writing to request [a standard/an expedited (select one)] external review of your denial of the claim for

assessment, treatment, or services provided by [name of provider on date provided].

The reason for denial was listed as [reason listed for denial on the plan’s internal appeal determination], but I have

reviewed my policy and/or discussed the treatment with my child’s provider and believe the treatment or service

should be covered.

Here is where you may provide more detailed information about the situation. Write short, factual statements.

You do not need to resubmit documents that you sent for your internal appeal. If you are including new

documents, include a list of what you are sending. For example:

•

Reference and attach letters from your child’s medical providers, including your child’s treatment plan,

prescriber’s evaluation or statement of medical necessity, provider’s progress notes, etc.

•

Reference and attach a copy of the internal appeal denial determination and the Plan’s EOB, if applicable.

•

Reference and attach proof of your child’s age and provide a copy of your child’s insurance card (if either age

or coverage is in dispute). Reference and attach proof of your child’s Autism Spectrum Disorder diagnosis (if

diagnosis is in dispute).

•

Reference and attach published research, if applicable.

•

Reference and attach any other new documents you wish to provide to support your appeal.

Please send me a list of the documents being sent to the CRE at the address below. I look forward to receiving your

response as soon as possible.

Sincerely,

Signature

Typed Name

Address

Email address

Phone #

Sample Letter To Request External Review Of Autism Assessment Or Treatment Denial