Sample Status Change Notification Letter
City, State, Zip
Dear Valued Patient,
An essential part of the doctor-patient relationship is communication. Because we are
making some changes in our office’s financial policy, we feel it is important to
communicate these changes to you.
Effective January 1, 2007, this office will no longer accept assignment for our Medicare
patients. Due to significant cuts in Medicare reimbursement, we have been forced to
change our status with Medicare from Participating Provider to Non-participating
provider in order to continue to provide quality patient care.
This change in status means that our Medicare patients will be asked to pay for their
services in full at the time of service. We will file a claim to Medicare on your behalf.
Medicare will send you a check reimbursing you for the services provided to you in our
On a case-by-case basis, we may accept assignment for patients requiring extensive
surgical services. In these instances, our patients will be asked to pay any unmet
deductible as well as the 20% copayment at the time of service.
We realize that even though we file the claim to Medicare on your behalf, a significant
number of our patients have secondary insurance. We hope that the instructions below
will help you to deal with your secondary/supplement insurance more easily.
At the end of each visit, each patient will receive a fully itemized receipt that is
acceptable for filing claims to their respective plan. This “itemized receipt” is usually a
completed insurance form that includes all necessary billing information.
If you are uncertain on how to file secondary claims to your carrier, follow the
instructions below or call _______, our office manager, at ( )____-_______ for
assistance. Please feel free to discuss your questions, comments, and concerns with
our manager. Our manager has been assigned the responsibility of discussing and
addressing any patient concerns.
Patient Instructions for Filing Secondary Insurance
1. Wait until you receive notification from your primary insurance that they have
made payment. This notification is referred to as an EOMB (explanation of
medical benefits) or MSN (Medicare Summary Notice). This is usually sent with
the check from Medicare.
This notification usually itemizes the total bill and clearly shows what the primary
insurance (e.g., Medicare) paid on the total bill.
2. Take a copy of this notification and attach it to a copy of the itemized receipt or
insurance claim provided by this office. If you have received a completed
insurance form, be sure that boxes 1a, 4, 6, 7, 11, 12, and 13 are completed
before you send the claim.
3. Your carrier may also require a special form to be attached to these two receipts.
If you have such a form, complete it and attach the two other forms to it.
4. Mail both to the address of your secondary/supplemental carrier.
5. Always keep copies of everything you send as insurance companies frequently
lose claims. We recommend that you make two folders; one for unpaid claims
and one for paid claims.
As the claims get paid, move them from the unpaid to the paid folder. If you don’t
hear from your carrier within two months of sending them a claim, you can call on
the unpaid claims more easily.
If you have any problems, contact ________ in the billing office and she will be more
than happy to assist you in filing your secondary claims.
We appreciate your cooperation in this matter.