(Health Plan) Appeals Department
Address
City, State, Zip Code
Subscriber's Name
Plan Member ID number
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 MCHCP handbook 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, please 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)
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