NEDA TOOLKIT for Parents
Sample Letter #1
Request that the copay for the psychiatrist from the patient be changed to a medical copay rate instead of the
higher mental health copay, because the psychiatrist was providing medication management, not psychotherapy.
Outcome Adjustments can be made so that the family is billed for the medical copay. Remember, the psychiatrist must use
the proper billing code.
Date: To: Name of Clinical Appeals Staff Person
INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB (Date of Birth)
Insurance ID#
Dear [obtain and insert the name of a person to address your letter to—avoid sending to a generic title or “To
Whom It May Concern”];
Thank you for assisting me with my [son’s/daughter’s] medical care. As you can imagine, this process is very
emotionally draining on the entire family. However, the cooperation of the fine staff at [INSURANCE COMPANY
NAME] makes it a little easier.
At this time, I would like to request that [INS. CO.] review the category that [Dr. NAME’s] services have been placed
into. It appears that I am being charged a copay for [his/her] treatment as a mental health service when in reality
[he/she] provides [PATIENT NAME] with pharmacologic management for [his/her] neuro-bio-chemical disorder.
Obviously, this is purely a medical consultation. Please review this issue and kindly make adjustments to past and
future consultations.
Thank you in advance for your cooperation and assistance.
Sincerely, [YOUR NAME]
Cc: [list the people in the company you are sending copies to]
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