Medical No Referral

{Your Name}
{Your Address}
{Your Phone #}

{Date}

Dear {Insurance Representative}:

I am writing with regards to a claim filed by {Provider} on {date} for {Patient}. The claim number is {number} and the total amount billed was {amount}. I have been informed that my claim was rejected, and I am respectfully requesting that you reconsider.

To the best of my knowledge, you are rejecting my claim based on the fact that I received out-of-network care without a referral. While I do not dispute this charge, I feel that, due to the medical necessity of my condition, I required urgent and immediate care. Unfortunately, my decision to go outside of my network was due to the fact that there was only one {clinic/physician} who could perform {procedure} in a {number}-mile radius.

I have enclosed a letter from my physician stating that {procedure} was a necessary procedure and completely medically justified. If I had not undergone the procedure, {negative consequence}.

I don't think I should be punished for seeking out necessary treatment, and I hope you can appreciate the unfortunate emergency I was in. Thank you for your time and consideration.

Sincerely,

{Sender Name}

Index of Hardship Letter Examples