Appeal letter - Global payment made to Facility - denial reason

Practice address

Phone# 407-123- 4567

_______________________________________________________________________
Date:

Careplus
Attn: Medical Records Department
4925, Independence Parkway Suite 300
Tampa, FL, 33634
Re: Appeal of Medical Claim

Patient Name:
Health Insurer Identification Number: 00101989701
Claim Number: 9111365798
Call Reference Number: 91111365797
Service Date: 09/18/2009


Dear Sir/Madam:

We are appealing your decision and requesting reconsideration of the attached claim that
was denied on 12/24/2009 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. (provider name) is the only Physician who interpreted the service (Professional
component only) performed at  MRI Outpatient Hospital on
09/18/2009. Hence Dr. is due and eligible to get paid for the professional
services that he had rendered.

• St. MRI 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. Mittal 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. Mittal's 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,
Henry Samuel
(Account Receivable – Reimbursement Specialist)

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