Free appeal letter 06Free appeal letter 06
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Note: This example is for instructional use only. Use the form provided by the payor, if available.
Contact name

Include all insurance company information, including the contact in

Company name

Appeal for coverage of VENTAVIS® (iloprost) Inhalation
Solution 2.5 mcg with 10 mcg/mL, 5.0 mcg with 10
Include all patient information, including health insur
mcg/mL, 5.0 mcg with 20 mcg/mL
Subscriber name:
Name of insured:
Policy number:
Reference ID, if available:
Prescriber name:
Prescribed on:

Include your information, including contac

Phone number:
Fax number:
Dear [Claims Representative]:

I am writing to request a review of a denied claim for [Patient name]. Your Cite reasons from payor response.
company has denied this claim for the following reason(s): [Fill in reason(s)
from Explanation of Benefits (EOB)].
[Patient name] was provided VENTAVIS® (iloprost) Inhalation Solution therapy
for the treatment of pulmonary arterial hypertension (PAH, WHO