CPT copyright 2016 American Medical Association. All rights reserved.
III. Elements of an Effective Appeal Letter
Generally, an appeal letter should contain the following:
Address the letter to one having the authority to make a decision on the claim, such as the Carrier Claims
Review Department Director or Carrier Medical Director.
RE: Claim #:
I am writing regarding the aforementioned claim and (Insurance Carrier Name)’s practice of
List the offending carrier practice (eg, bundling codes, not recognizing codes).
Provide rationale as to why this practice is unacceptable to the pediatrician, the patient, and fair business
practice. Reference appropriate CPT® guidelines, contract language, fee schedule, and state or federal law.
State how the situation is to be rectiﬁed and what you expect the carrier to do. Specify a time frame for a
response and how the carrier may reach you should it have any questions.
Enclosed is a copy of the original claim that was submitted with a request that you process payment as indi-
cated on the claim. I look forward to receiving your response by (date).
If you have any questions, please feel free to contact me at _______________________________________.
Also available at www.aap.org/cfp, access code AAPCFP22.