Out-of-network claim reconsideration

A general reconsideration letter for an OON claim that was denied, underpaid, or bounced for missing information (CARC 16, 252). Use it to ask the payer to re-review and reprocess.

The letter

[DATE]

[PAYER NAME]
Attn: Claims Review / Appeals Department

Re: Request for claim reconsideration
Patient: [PATIENT NAME]
Date of birth: [PATIENT DATE OF BIRTH]
Member ID: [MEMBER ID]
Claim number: [CLAIM NUMBER]
Date(s) of service: [DATE(S) OF SERVICE]
Procedure code(s): [CPT CODE(S)]

To whom it may concern:

I am writing to request reconsideration of the above claim, which was [DESCRIBE HOW IT WAS PROCESSED — e.g. denied / underpaid / returned for missing information] on the remittance dated [REMITTANCE DATE], reason code [DENIAL CODE FROM THE REMITTANCE].

[EXPLAIN, IN YOUR OWN WORDS, WHY YOU BELIEVE THE CLAIM SHOULD BE RECONSIDERED — for example, the information the payer indicated was missing, the basis for the billed amount, or the benefit you understand applies.]

I have enclosed [LIST WHAT YOU ARE ENCLOSING — e.g. a corrected claim, proof of the patient's out-of-network benefits, an itemized statement].

Please re-review this claim and reprocess it according to the patient's out-of-network benefits. I can be reached at [PROVIDER PHONE] with any questions.

Sincerely,

[PROVIDER NAME AND CREDENTIALS]
NPI: [PROVIDER NPI]
[PROVIDER ADDRESS]
[PROVIDER PHONE]