APTA has created a variety of template letters you and your patients can use when your patient is denied coverage, the services approved are inadequate, or care is delayed, and a utilization management company is involved.

Commercial Template Letters

APTA Template Letter: Provider to Payer to Request Code Exclusions Policy Change
Use this letter to convey the adverse impact of a coding exclusion on your clinic’s patent population and to request a change in policy.

APTA Template Letter: Consumer to Payer for Denial Based on Code Exclusions
Share this letter with your patients to use in reporting their specific concerns and individual adverse impacts related to a coding exclusion implemented by a health plan.

APTA Template Letter: Provider to Payer to Request Reconsideration of Adoption of PTA Payment Differential
Use this letter to convey the adverse impact of the PTA payment differential on access to care for your clinic's patent population and to request a change in policy.

Templates for Commercial Payer Issues

You can use these letters to request policy changes or address claims denials.

• APTA Template Letter: Provider to Payer to Request Code Exclusions Policy Change
  Use this letter to convey the adverse impact of a coding exclusion on your clinic’s patent population and to request a change in policy.

• APTA Template Letter: Consumer to Payer for Denial Based on Code Exclusions
  Share this letter with your patients to use in reporting their specific concerns and individual adverse impacts related to a coding exclusion implemented by a health plan.

Templates for Prior Authorization Issues

You can use these letters when your patient is denied coverage, the services approved are inadequate, or care is delayed, and a utilization management company is involved.

• Letter to Legislator Re: Subcontracted Company Causing Issue – Outpatient Services
  If your patient is enrolled in any type of health insurance plan that subcontracts with a utilization management company, use this letter to inform your legislator of the issues your patients (their constituents) are having in accessing their health care, as well as the challenges your business faces in dealing with this company.
• Letter to Legislator Re: Medicaid Issues with Managed Care Organization/Medicaid
  If your patient is a Medicaid beneficiary who is enrolled in a Medicaid plan administered by a managed care organization, use this letter to inform your legislator that the company the state contracted with to provide Medicaid services is creating barriers to care.
• Letter to State Medicaid Office Re: Issue Managed Care Organization
  If your patient is a Medicaid beneficiary who is enrolled in a Medicaid plan administered by a managed care organization, use this letter to inform the Medicaid Office in your state that the company they contracted with to provide Medicaid services is creating barriers to care.

Templates To Help Your Patients Be Their Own Advocate

Insurance providers are legally required to respond to consumer complaints. These letters should be shared with your patients as a way to communicate with their employers, representatives and officials. Remind your patients that their representatives pay attention when a patient raises a concern!

• Patients Be Your Own Advocate (Know Your Rights)
  Educate your patients on their rights to health care coverage. If they have been denied services, provide this document as a way to help them appeal to their representative or official. Complete as much of the form as possible, and indicate to your patient what they need to complete.
• APTA Template: Consumer Letter to Legislator – Basic 
  Share this letter with your patients to use in sending a complaint to their state legislator. They should explain the type of plan they have as well as the difficulties they are having in receiving care.
• Letter to Legislator Re: Medicaid Benefits Issues with Managed Care Organization
  This letter is for your patients who are Medicaid beneficiaries enrolled in a Medicaid plan administered by a managed care organization, to inform their state legislator that the company the state contracted with to provide Medicaid services is creating barriers to care.
• Letter to State Medicaid Office (Medicaid beneficiary)
  This letter is for your patients who are Medicaid beneficiaries enrolled in a Medicaid plan administered by a management care organization, to inform their state Medicaid Office that the company they contracted with to provide Medicaid services is creating barriers to care.
• Letter to Employers
  This letter is for your patients to send to their employers, asking them to intervene when a UM vendor is impeding or denying access to services provided through the company’s health plan.
• APTA Template Letter: Patient to Payer to Request Reconsideration of Adoption of PTA Payment Differential
  Share this letter with your patients to use in reporting their specific concerns and individual adverse impacts related to the adoption of the PTA differential by a health plan.

APTA is here to help! If you aren’t sure where to start in addressing an issue, or when you notice a reoccurring issue, please contact staff at advocacy@apta.org.