Audit Hospital Bill

Date: [Current Date]
To: Billing Director, [Hospital Name]
Address: [Hospital Billing Department Address]

RE: Formal Request for Financial Hardship Review and Balance Negotiation
Patient Name: [Your Full Name]
Account Number: [Your Account Number]
Original Billed Amount: [Total Billed]

Dear Billing Director,

I am writing to formally request a financial hardship review of my outstanding balance. Due to recent financial circumstances, including [briefly mention context, e.g., loss of income, high cost of living, fixed retirement income], paying the full billed amount would cause severe financial distress to my household.

I have thoroughly reviewed the summary of charges and am requesting that my balance be adjusted in accordance with your Financial Assistance Policy (FAP). My household income is currently [Your Monthly/Annual Income], which places me at [Percentage]% of the Federal Poverty Level.

I would like to propose a final lump-sum settlement of [Proposed Amount, e.g., 30% of total bill] to completely resolve this debt, or alternatively, an interest-free payment plan of [Amount, e.g., $50/month] for [Number] months.

Please provide me with your formal financial assistance application forms and confirm that this account has been placed on an administrative hold to prevent any negative reporting to credit bureaus during this review process.

Thank you for your time, consideration, and support.

Sincerely,

[Your Signature]
[Your Printed Name]
[Your Phone Number]
[Your Email Address]

Date: [Current Date]
To: Member Appeals Department, [Insurance Company Name]
Address: [Insurance Claims Appeal Address]

RE: Formal Appeal of Claim Denial
Policyholder Name: [Policyholder Full Name]
Patient Name: [Patient Full Name]
Policy/Member ID Number: [Your Policy ID Number]
Group Number: [Group Number]
Claim/Reference Number: [Claim Number]
Date of Denial Notice: [Date of Denial Letter]
Date of Service: [Date the procedure occurred]

Dear Appeals Committee,

I am writing to formally appeal your decision to deny coverage for [Name of Procedure/Service], billed under CPT Code [Insert Code] by [Hospital/Provider Name] on [Date of Service].

Your denial letter dated [Date of Denial Notice] states that coverage was denied because [Insert Reason from Denial Letter, e.g., "not medically necessary" or "out of network"]. I disagree with this determination.

[Choose Option A or B]
[Option A: For Out-of-Network Emergency Services]
This procedure was administered during an active emergency medical crisis. Under the federal No Surprises Act, out-of-network surprise billing for emergency services is strictly prohibited, and coverage must be processed at in-network rates.

[Option B: For Medical Necessity Denials]
This service was directly ordered by my treating physician, Dr. [Doctor's Name], as a critical component of my medical treatment. I have enclosed a formal Letter of Medical Necessity from Dr. [Doctor's Name] explaining why this service was medically required for my diagnosis.

Please re-evaluate this claim and reverse the denial. I request a complete review of my medical records and a formal written response within the statutory timeline.

Sincerely,

[Your Signature]
[Your Printed Name]
[Your Phone Number]
[Your Email Address]

Enclosures:
- Copy of original Denial Notice
- Letter of Medical Necessity from Dr. [Doctor's Name]
- Relevant Medical Records / Lab Results