Denied claims remain common for private practices. A 2025 analysis reported a 16% rise in claim denials from 2018 to 2024.

Many teams still hesitate to challenge those claim denial decisions. The AMA found only 20% of physicians always appeal adverse prior authorization outcomes, often citing time and confidence barriers. 

A clear denial letter shows what to fix and where to begin in the appeals process. Patients also have formal rights under health insurance rules and their health plan policy. 

A successful appeal begins with clear, concise communication through a medical appeal letter that:

A short, complete packet helps claim reviewers find what they need fast. Use the checklist below and keep the same identifiers on every page.

Ask the insurer to route the case to a physician in the relevant specialty. Share the appeal with the patient and request their engagement to provide additional information that may be helpful. Ask them to confirm prior authorization status and any notices they received.

Revenue cycle expert Elizabeth Woodcock of Woodcock and Associates drafted the sample appeal letter below so you can customize it for your needs. Before sending, replace every placeholder with your identifiers as noted below.

Date 

[Insurance company name]

[Mailing address]

To Whom It May Concern:

Thank you for the opportunity to submit this appeal for reconsideration of payment. We are contacting you about services rendered to [patient name, date of birth, policy number, group number, health plan, dates of service, and services rendered].

This service was denied on [date]. According to your communication, the decision is described in the denial letter for [reason]. The attached EOB shows the denial and reason code. We also spoke with your representative by phone on [date] at [phone number] and documented [reference code]. This letter formalizes our request for reconsideration.

Your notice states that the diagnosis does not support the service and that it is not medically necessary, or that prior authorization was missing. We are enclosing clarifying details and any additional information you requested. 

Please confirm next steps in the internal review and the appeals process, and advise if the case should proceed to an external review under the plan's [policy name] and the federal external review timelines.

The services were medically appropriate and met plan criteria for medical necessity. We have attached relevant medical records, including the medical history, progress notes, and the treatment plan that guided care. Peer-reviewed literature supporting this approach is included as supporting documents and listed as enclosures. For clarity on definitions, we also reference the AMA's definition of medical necessity.

As the treating physician, I have provided a brief statement explaining the clinical rationale and why the selected setting and timing were appropriate for this patient. If the health plan requires consultation by a physician in the relevant specialty, please route the review accordingly.

We would be glad to discuss the case at your convenience. You may reach me at [phone number]. The signature block below includes [physician name], credentials, and [NPI] for verification.

Sincerely,

[Physician signature block with physician name and NPI]

Attachments:

Follow Elizabeth Woodcock's guidance and make these refinements:

Appeals are most effective when the letter is clear, the evidence is complete, and the follow-up is consistent. Keep identifiers on every page, align your case to the plan policy, and send concise supporting documents.

A proactive submission process helps a healthcare provider avoid costly rework. Accurate documentation in your EHR software supports clean claims by aligning codes, notes, and supporting documents with payer rules. 

For practical next steps, use this step-by-step guide to reduce claim rejections, then track outcomes with your health insurance payer reports to spot patterns early. And book a free, personalized demo today to see how Tebra helps your practice submit clean claims.