HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers

If you receive a bill that you believe your medical group or health plan should pay, begin by reading the bill. Call whoever sent the bill to find out if your health plan or medical group has been billed. You may also need to contact your medical group or health plan customer service departments. If you call your health plan or medical group, keep notes of who you spoke to and what was said. If you have talked to your medical group and health plan, and the billing issue is still unresolved, you may want to request in writing that your medical group or health plan pay the bill. You may need to appeal the denial of payment. This letter provides a basic format for making such a request or appeal. Be sure to add your own facts to this letter.

• All of the language suggested may not apply to you. Use only the parts of the letter that are appropriate based on your facts.
• Places where you can insert your information are identified by brackets ("[ ]"), and the description of the information to add is underlined. You should delete the brackets and the sample description, and fill in your own information, where it applies.
• The letter includes advice to you that is in parenthesis ("{ }"), with the text of the advice in italics. You should delete these sections from your letter.
• The sample letter is addressed to the "Customer Service Department." Your health plan may use a different name for the department that receives complaints, grievances and appeals from its members. Check your health plan documents or member handbook [usually called the Evidence of Coverage (EOC) or Summary Plan Description (SPD)], or call your medical group or health plan, to find out to whom your letter should be sent.
• Check your health plan documents or member handbook (EOC or SPD) for your plan's requirements for filing a complaint, grievance or appeal. You should follow your health plan's procedures, including any time limits, when you file a complaint, grievance or appeal.
• There are different laws that apply to different types of health care coverage. The laws that apply in your circumstances may depend on where you live, what type of health plan you have, and how you get your coverage. Check your EOC for information about the agency that regulates your health plan, then check with the agency to see what set of laws apply to your case. Remember, it is not necessary to quote the law in your letter, but doing so may help make your case stronger.

• Attachments - You should attach to your letter copies of any information that helps explain your case. Support from your doctor is usually very important if you are requesting your health plan or medical group to cover a certain procedure or treatment. See the Health Right's Hotline's Action Guides, "How to Appeal a Health Plan or Medical Group Decision" and "Learning About Your Medical Condition," for more information on what you may want to attach to your letter. At the end of the letter are examples of the sort of attachments you might want to include. In some cases, a letter may have no attachments; in other cases, there may be many.
• Sending Copies - Consider sending copies of your letter to others who may be helpful in resolving your problem. Suggestions for who you might want to send copies to are listed at the end of the letter. You should decide who might be helpful in resolving, and who you would like to know about, your problem. It probably is not appropriate for you to send copies of your letter to all who are listed on the sample letter under the "cc."
  

  Health Rights Hotline

  Sample Letter for Billing Problems

  (see tips for using this letter)

   

  [Date]

   

  [Your Medical Group or Health Plan]
  Customer Service Department
  [address]

   

  RE:	Appeal for [your name]
  	Subscriber #[your number]

  
  

  Dear Customer Service Department:

  I am writing to 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 [dollar amount] and must be paid by [date]. I believe this bill should be covered by my [medical group OR health plan]. I called the [medical group OR health plan] on [date(s)], and I spoke with [name of representative] concerning the bill, but the problem has not yet been resolved.

  I believe this bill should be paid by [name of medical group OR health plan] because: {List specific reasons you think the bill should be paid. Possible reasons are listed below. Choose as many reasons to include in your letter as apply to you. The first reason probably should be included in any billing letter.}

  • [name of service] is a covered service under my health plan coverage terms;
  • a referral for [service, treatment, OR procedure] was provided by my primary care physician;
  • [service, treatment OR procedure] was performed by my primary care physician;
  • [service, treatment OR procedure] was performed by a specialist to whom I was referred by my primary care physician;
  • the 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 copayment or deductible obligations under the health plan's coverage terms;
  • I could not get prior authorization before receiving [service, treatment, OR procedure] because my health care problem was an emergency. I did call my [primary care physician, health plan or medical group] as soon as I could after receiving the [service, treatment, OR procedure], as required by my health plan.
  • The [medical group OR health plan's] failure to pay the bill violates [federal AND/OR state] law which requires [applicable legal requirement]. {You can refer to the code section under the law that applies. For example, HMOs in California are required to pay for certain services: (See Cal. Health & Safety Code § [code number].)}

  Attached is documentation supporting your responsibility for the bill.

   Please respond in writing and let me know what actions you will take regarding this request. Thank you for your prompt attention to this matter.

   Sincerely,

  [Your name]

   

  cc: {Possible individuals and/or groups to whom you can consider sending copies of your letter are:}

  [Your primary care physician]
  [Billing party]
  [Medical group]
  [Health plan]
  [Your employer or insurance broker]
  [State regulatory agency]

   

  Attachments: Copy of bill dated [date]

  {Material and documentation you can consider attaching are:}

  • Copies of portions of plan member handbook or EOC stating coverage terms, (i.e. specific coverage provisions, and/or definition of medical necessity and list of exclusions and limitations);
  • Copy of referral;
  • Copy of letter from doctor;
  • Medical records;
  • Medical journal articles supporting medical necessity of care received.