Medical Out of Network

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

{Date}

Dear {Insurance Representative}:

I am writing to request reconsideration for a claim denial that was filed by {Provider} on {date} for {Patient}. The claim number is {number} and the total amount was {amount}. On {date}, {insurance plan} denied any coverage for the claim due to the fact that the medical treatment was received at {establishment}, which was out of the plan's network.

I am requesting reconsideration of this claim based on its medical necessity. I have included a letter from my medical provider stating that not only was the procedure medically necessary and completely justified, but the situation was an emergency that required immediate attention. Even so, I made every effort to find a provider within my network for this procedure. There was no one within a {number}-mile range and, as I said before, the situation was an emergency.

I don't think I should be penalized for having a necessary procedure that was not available within my network. I respectfully ask that you reconsider the denial in light of the necessity of the situation.

Thank you,

{Sender Name}

Index of Hardship Letter Examples