Letter of Appeal
Date:
Insured’s Name:
Patient Name:
ID#:
Date of Service:
Dear Claims/Appeals Department,
Please review the following information regarding the services I received at the Telluride Medical Center (TMC) and reconsider the benefit payment.
The Telluride Medical Center is licensed as a CCEC (Community Clinic and Emergency Center) in the state of Colorado. They are also certified as a Level V Trauma center. TMC is not a hospital, but they have a fullyequipped Urgent Care facility that is staffed 24 hours a day, 365 days a year with board-certified physicians and trauma certified RN’s. Telluride is in a rural area with limited healthcare facilities and the closest hospital is 65 miles away, over a 10,000 foot mountain pass, in Montrose, Colorado.
The facility fees (CPT 99499) that are billed include the professional nursing care and monitoring I received. Any supplies and medications billed were provided because I needed them immediately and/or they were not available at that time from another source.
Please reconsider the denied charges and send any additional benefits to me. I will be happy to assist in obtaining any additional information. Thank you for your time and consideration.
Very truly yours,
