Medical Claim Letter

A Medical Claim Letter is a document sent to an insurance provider, managed care organization, or another type of insurer to request coverage of or reimbursement for any completed medical procedures. While health care providers often submit claims directly to insurers, there are situations in which the health care provider may not provide this service, particularly if the health care provider is considered out of network with the insurer. In these instances, patients, or their representatives, must submit the claim themselves using a Medical Claim Letter.

How to use this document

This letter includes all of the relevant information, such as the name of the patient, the name of the health care provider, and the date the service was rendered, that an insurer will need to process a medical claim. There are also additional documents that can be enclosed with this letter, such as a letter from a health care provider explaining the nature of the medical procedure and why it was provided. The insurer might also have their own claim form that must be completed. If this is the case, the insurer's claim form should be completely filled out and sent in along with this letter.

There are no laws dictating the substance of Medical Claim Letters. However, the insurer may have particular information that must be included in order for a claim to be processed and approved. Before sending this letter, the individual making the claim should check the insurer's website or help hotline service to be sure this letter includes all of the necessary information.

Once this letter is done, it should be sent via certified mail so that the sender has a record that the letter was received by the insurer. The sender of this letter should also keep a copy of the letter, in case of future dispute.

Applicable law

Health insurance and coverage is governed by both state and federal laws. The main federal law that applies to health insurance is the Affordable Care Act (ACA). The ACA works to make health insurance coverage more available and has provisions about who should be eligble for health insurance. It forbids health insurance companies from denying coverage to individuals due to pre-existing conditions. Another law that concerns health insurance, specfically insurance provided by an employer, is the Employee Income Retirement Security Act of 1974 (ERISA). ERISA controls minimum standards for voluntarily established health plans in private industry to provide protection for individuals in these plans.

How to modify the template

You fill out a form. The document is created before your eyes as you respond to the questions.

At the end, you receive it in Word and PDF formats. You can modify it and reuse it.