(Medical Plan) Appeals Department
Address
City, State Zip

Subscriber’s Name
Subscriber’s SSN
Re: Member’s name for whom appeal is being submitted

To Whom It May Concern:

Enclosed, find your explanation of benefits dated (date) for claim number (###). The claim was denied for (list reason on EOB). I wish to appeal this decision.

I have attached a copy of the summary plan description page(s) which state(s) (whatever service was denied) is a benefit. Enclosed, find a copy of the medical records, Dr. (name)’s referral, and a copy of the expenses incurred.

Please review this claim for payment. If you continue to deny this claim, provide a detailed explanation of your denial. Your prompt attention to this matter is greatly appreciated. I look forward to hearing from you within 30 days.

Sincerely,
(Your name)