(Date) (Attn: insert name or department) (Insurance company name) (Ins. Co address) Re: Insured: ID #: Date of Service: Provider: Claim number:
Dear Sir or Madam: I received the explanation of benefits and the bill from the provider. It was explained to my wife by (insert insurance company or name of person you spoke to here), that my portion was so high due to the provider being out of network. I would like to submit an appeal for this provider. As this procedure was scheduled in an emergency situation, subsequent to my two trips to two different emergeny rooms for sever gallbladder pain. My gallbladder and liver ended up beign twisted together, so as you can imagine I was in extreme pain. During that time there was no discussion about this not being a participating provider. I was out of my mind in pain, all procedures were then scheduled in emergency fashion. I respectfully ask that due to the emergent nature of the procedure, that you make an exception regarding paying this bill. The physicians made all arrangements due to severe nature of my pain and due to those circumstances, the option to stay in network was not something available to me as they were made in an emergent situation. I thank you for your time and attention to this matter. Very Truly Yours,