Date: (mm/dd/yy)
Group Name:
Client/Insured Name:
Provider Name:  
Provider Number:
From:

Description of Issues:
a procedure for which payment was not made by the insurance company
hospitalization/procedure performed out-of-area
your responsibility for partial payment for a procedure
in-network services rendered, but billed as out-of-network
Medical coverage
medical insurance, worker's compensation, and/or disability insurance
     reimbursement applied to medical benefits
coverage of a pre-existing condition
prescription coverage (e.g. generic vs. brand name)
assistance with mail-order prescription program
other, please specify:

Resolution of Issues:
the charge has been applied to your yearly deductible
the charge has been applied to your yearly coinsurance
this procedure is considered more than reasonable and customary
you did not receive a referral for this procedure
the doctor who performed the procedure is out-of-network
this procedure is not covered under your plan/policy
this claim was sent to your previous plan/insurance company
you did not receive pre-authorization for the hospital stay/procedure
you are responsible for an emergency room copayment
your dependent was not covered because:
           dependent is a newborn who was not registered after 30 days form birth
           dependent is no longer eligible for coverage
claim was paid, please inform the collection agency
your coverage has been terminated as for
other, please specify: