Generic Appeal Letter

This template may be used to write an appeal in the event that your request for a prior authorization was denied. You may choose to download the blank Word document or use the convenient form template below. If we can be of further assistance, please contact us at (800) 394-4493.

Physician InformationPatient & Insurance InfoDisorder and Test Information

Physician Information

Name:
NPI#:
Hospital/Institution:
Address:
Address 2:
City:
State:	Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
Zip:
Phone Number:
Contact Hours:

Patient Information

Patient Name:
DOB: (MM/DD/YYYY)
Gender:	male female

Insurance Information

Medical Director Name:
Insurance Company:
Insurance Company's Address:
Address 2:
City:
State:	Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
Zip:
Member ID:
Group ID:
DOS: (MM/DD/YYYY)
Reason for denial:

Disorder and Test Information

Name of Suspected Disorder:
Name of Athena Test:
Type of Test:	genetic antibody
CPT Codes: Separate by comma or copy and paste from website	Search for CPT codes
List Primary Clinical Symptoms:	1. ICD-9: 2. ICD-9: 3. ICD-9: 4. ICD-9: 5. ICD-9: 6. ICD-9: 7. ICD-9:
Risks of Not Testing along with cost implications of a misdiagnosis:
Quote from reprints/expert opinon:
Attachments:
References to peer reviewed journals:
Athena's benefit:	Example: Athena is the only Lab that can perform this testing; Athena's test has a higher sensitivity than other labs