Appeal letter sample: Mental Health Benefits


Template letter for patients requesting extensive or coverage for mental health benefits. Healthcare provider completes and patient submits request for coverage/extension of coverage to insurance provider.

SAMPLE LETTER BELOW

MM/DD/YYYY

Re:  PATIENT NAME
DOB:  MM/DD/YYYY

Dear Sir or Madam:

This letter is being written on behalf of our patient, Patient Name, whom we follow for his/her diagnosis of Crohn’s disease/ulcerative colitis, a chronic inflammatory bowel disease of the colon and intestines. We submit this letter in support of his/her being permitted to receive out-of-network benefits in the Department Name at Hospital Name, as a clinical case exception. Patient Name has had a complicated course of his/her illness, Description of Patient History.

Patient Name’s illness’ response to our treatment plan has been sporadic and inconsistent, causing great stress on his/her mind and body. We know that the emotional and physical pieces are interrelated in complex ways, and patients can experience exacerbations of disease activity during times of emotional tensions and stress. This can relate to changes in the physiologic functioning of the gastrointestinal tract; we have seen this occur with Patient NameHis/Her medical complications have led to periods of intense stress and pressure, thereby exacerbating symptoms of her disease. Patient Name’s specific circumstances are physically and psychologically complicated, and it is crucial to be able to integrate the medical and psychiatric services at Hospital Name; this will be critical to providing the most comprehensive and cost-effective care.

In our Department Name, we have Description of Department Resources and Proven Benefits to Patients.

Patient Name’s ability to access the services of Department/Resource(s) Name could be essential in reducing the risk factors for a necessary medical or psychological hospitalization. A hospitalization would be much more costly, both financially and in terms of the missed developmental learning opportunities in the social and academic realms.

Specific request of insurance company (Eg. Number of covered visits with out-of-network group)

Please understand the extenuating circumstances impacting Patient Name. Thank you very much for your time and consideration in this urgent matter. We look forward to hearing your response.

Please call my office at Phone Number, if you have any further questions.

Kind regards,

SIGNATURE



For further information, call CCFA at our Information Resource Center: 888.MY.GUT.PAIN (888.694.8872).

The Crohn’s & Colitis Foundation of America provides information for educational purposes only. We encourage you to review this educational material with your health care professional. The Foundation does not provide medical or other health care opinions or services. The inclusion of another organization’s resources or referral to another organization does not represent an endorsement of a particular individual, group, company or product.

About this resource

By: CCFA
Published: May 1, 2012

Downloads available

Mental Health Benefits (.doc)
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