Name of Insurance/Carrier
Date
Attn: Director of Claims
Insurance company name
Insurance company address
Re: Claim #:
Patient Name
Patient’s ID #:
Dates of Service:
Total Billed Amount:
Dear [medical director’s name]:
On [date of service] I performed a [name of service or procedure] on the above-mentioned patient. There is no specific CPT code for this procedure/service; therefore, I am submitting the unlisted procedure code [insert CPT code and descriptor].
The procedure performed on [insert patient name] may be reasonably compared to existing CPT code [code number and description] in terms of physician work and practice expense. [define here what the procedure entailed and how much more/less difficult it was than the base CPT code].
My charge for (the comparator base existing CPT code) is $________. I estimated the charge for the submitted unlisted procedure to be [list percent that procedure is less or more difficult than base code] for the reasons mentioned above. Therefore, I have submitted a charge of $__________ for this procedure. Attached, please find a detailed copy of my operative report/office notes and a claim on the above-mentioned patient.
Sincerely,
Doctor/Group Name
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- name of different countries
- name of different countries in the world
- find name of song with full lyrics
- name of technology
- find the name of a song
- what is the name of symbol
- dept of insurance of nevada
- find name of song by words
- name of ministers in ghana
- name of profession
- no name car insurance companies
- name of ministry of bangladesh