Appeal Request Letter

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ON YOUR LETTERHEAD

REQUEST FOR INTERNAL APPEAL/SECOND
LOOK FROM PIP DENIAL, REDUCTION, AND/OR
NON-PAYMENT

DATE:       

TO:       
RECIPIENT’S FAX NUMBER:       

RE:       
CLAIM #:

FROM: 

TOTAL PAGES, INCLUDING COVER:      

MESSAGE:  REGARDING THE CAPTIONED MATTER, KINDLY ACCEPT THIS LETTER AS OUR FORMAL REQUEST FOR AN INTERNAL APPEAL/SECOND LOOK IN ACCORDANCE WITH THE TERMS OF YOUR PIP POLICY.  PLEASE RE-REVIEW ALL RECORDS, REPORTS AND DOCUMENTATION WE HAVE PREVIOUSLY SUPPLIED IN OUR PRIOR NOTICES, PRE-CERTIFICTION REQUESTS, APPEALS, and BILLING ALONG WITH THE ATTACHED ADDITIONAL RECORDS AND DOCUMENTATION.

We hereby appeal any and all denials, reductions, and non-payments of services.  All the services requested and/or provided are medically necessary, reasonable and causally related to the MVA.  All fees billed are our usual, customary and reasonable fees subject only to the NJ Fee Schedule.

The information contained herein is confidential.  Further dissemination is prohibited.

Thank you,

Your Name

DISCLAIMER The information provided herein is in no way intended to establish an Attorney-Client relationship. Given the changing nature of the Law, business and the legal profession, the Law Offices of Sean T. Hagan, LLC does not and cannot warrant or assure that the information herein is complete, accurate or up to date. We do not assume, and therefore disclaim, any responsibility or liability for loss or damage caused by errors or omissions, whether resulting from negligence or any other cause. The material contained herein is not intended for, nor may it be used for legal advice in any general or particular sense. Readers are encouraged to consult us directly as to the current law applicable to particular situations. Copyright 2008 NJPIPRecovery.com