Denial Letter and Appeal Notification for Treatment Auth

Appendix BB

Treatment Denial Letter and Appeal Notification

Form Approved

OMB No. 0920-0891

Exp. Date XXXXXX

Re: <Member ID#>

<Date>

Dear <First Name> <Last Name>:

This letter is to inform you that a specific treatment for your certified health condition [NAME OF HEALTH CONDITION] has been determined not to be medically necessary. The treatment has been determined not to be medically necessary because [REASONS]. The World Trade Center (WTC) Health Program will not provide any benefits associated with this specific treatment of your certified health condition.

This determination will become final 120 calendar days from the date of this letter unless you file an appeal.

Appeal Rights

If you believe the denial of treatment benefits was made in error, you or your representative may appeal the denial by sending a written letter to the Administrator, WTC Health Program, at the following address: WTC Health Program, 327 Columbia Turnpike, Rensselaer, NY 12144.

The letter must be sent within 120 calendar days of the date of this letter. The information you submit with your appeal should include a complete explanation of the specific reasons you feel the denial is incorrect.

Please note that all appeal letters must be signed. Your signature indicates that the information you provided is correct to the best of your knowledge. If you have questions about this letter or the appeal process, please send your question to the mailing address provided above or call the WTC Health Program at 1-888-982-4748.

Public reporting burden of this collection of information is estimated to average 90 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, Georgia 30333; ATTN: PRA (0920-xxxx).

Sincerely,

John Howard, M.D.

Administrator, World Trade Center Health Program

Copy to: Director, Clinical Center of Excellence