RE: (Name of Patient)
(Claim Number:)

To Whom It May Concern:

Please accept this letter as notification of my authorization as representative to act on behalf of (insert name of patient) in the above-referenced claim matter. Attached is a copy of the authorization for your records. This is also notification and request for an appeal of the recent benefit denial (specify the denial dates of services and attached related denial materials) as further outlined in the attached materials. This authorization and request for an appeal is submitted pursuant to 29 USC §1133 governing health benefit plan subject to the Employee Retirement Income Security Act of 1974 (ERISA), and requiring ERISA plans to:

1. Provide adequate notice in writing to any participant or beneficiary whose claims for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant and to

2. afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim.

Therefore, in connection with the above-referenced statute and the related claims regulations codified at 29 CFR §2560.503-1, I request as authorized representative the following:

A. Plans, policy and procedures for filing an appeal and obtaining a review of the above-referenced denied services;
B. Any additional requirements you may have for representative authorization;
C. All internal rules, guidelines, protocol or similar criteria relied upon in making the adverse benefit termination;
D. The identification of medical or chiropractic experts whose advise was obtained on behalf of the plan in connection with the adverse benefits termination;
E. Copies to all documents, records and other information relevant to the adverse benefit decision. Such relevant documents to include that:
a. was relied upon in making the benefit determination;
b. was submitted, considered, or generated in the course of making the benefit determination, without regard of whether it was relied upon;
c. demonstrates compliance with the plans administrative processes and safeguards for ensuring consistent decision making; and
d. constitutes a statement of policy or guidance with respect to the group health plan concerning the denied treatment option or benefit for the claimant’s diagnosis without regard to whether it was relied upon in making the benefit determination. See Section 2560.503-1(h)(2)(iii) and Section 2560.503-1(m)(8) of the above-referenced claims regulation.

Finally, I would request on behalf of my patient a copy of the summary plan description required to be maintained by the plan and provided upon request to the plan beneficiary under ERISA.

Thank you for your cooperation. I look forward to receiving the requested materials and pursuing the appeal of the adverse benefit determination[s].

Sincerely,
(Name of Doctor)

CC: (Name of Patient)