Date
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 [Director of Claims]:
We are in receipt of your payment for the above-referenced claim. However, it is our position that your company failed to reimburse properly for services rendered on this date.
The patient received an evaluation and management (E/M) service [list the code number and descriptor] on the same day that another service or procedure [list the code number(s) and descriptor(s)] was performed. The claim was filed with the appropriate modifier linked to the E/M: -25 significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.
It is our position that the E/M component is different than and separate from the normal pre-, intra-, and post-service care associated with this procedure. [Explain how the E/M is separate from the other service(s) or procedure(s), eg, different work, diagnosis].
Please reprocess this claim, allowing benefits for the E/M service. If no additional benefits will be released, we will appreciate your written response with supporting documentation from CMS Correct Coding Initiative guidelines or any applicable internal policy guidelines.
Sincerely,
Patient Accounts Manager
................
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