Reimbursement Appeal Decision Letter

W orld Trade Center

Health Program

Form Approved

OMB No. 0920-0891

Exp. Date XXXXXX

Date

Re: Claim appeal / Pricing appeal / Name of specific appeal for claim # xxxxxx

Name of person sending in appeal

Address

This correspondence addresses your letter of appeal dated xxxxx, 2016 for claim # xxxxxxxxxxxxx. The appeal letter reads:

Quote the appeal letter / document.

Provide appeal decision. Explain response.

• Pricing:

• Backdating certification:

• Adding code to Codebook:

• Others as applicable:

Include any supporting documentation such as FECA Fee Schedule for pricing appeals or Codebook for the respective code and date.

The Office of Workers’ Compensation FECA fee schedule file can be retrieved here: https://www.dol.gov/owcp/regs/feeschedule/fee/fee15/fs15_code_rvu_cf.pdf.

The Office of Workers’ Compensation Geographic Practice Cost Index file can be retrieved here:

https://www.dol.gov/owcp/regs/feeschedule/fee/fee15/fs15_gpci_by_msa-ZIP.pdf.

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta.

Regards,

<Reviewer Name>

Medical Claims Review Nurse

World Trade Center Health Program

FirstName.LastName@csra.com

888-982-4748

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