Appeal Request Letter
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ON YOUR LETTERHEAD
REQUEST FOR INTERNAL APPEAL/SECOND
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.
The Law Offices of