Part IV: The Denial
Dear Ms. Hoshi Sato,
This is an official notice from the offices of Stellar Healthcare Insurance Triumvirate. We have reviewed the information regarding the treatment of parasitic nematotitis as requested by Dr. Phlox of Denobulan. After careful consideration, we are unable to approval this request under the exclusion clause per your Evidence of Coverage. We regret we cannot authorize this treatment. The treatment you seek is not covered by the binding insurance plan you have chosen. For your convenience we have attached a copy of your signed contract for your review. Under Section II, Chapter V, Part IV, Division XI, Paragraph III, it states the various reasons for the Denial of Coverage (this is not a comprehensive list, see Appendices IV:Part II, X:Part XI, XII:LX).
A copy of a more detailed decision matrix is available upon request. A Plan Accountant is available to speak to your doctor regarding approved treatments and medical alternatives. Your health is our priority and our account representatives are here to help your doctor provide the best treatment available to you in accordance with your selected S.H.I.T plan.
You have the right to appeal decision rendered but you must complete and submit the S.H.I.T appeal forms. Appeal forms must be filed in triplicate with an appeal processing number within two days upon the receipt of this letter. The number can be obtained by calling our members services, Mondays 12-5 PM EST. Due to heavy call volumes, it can take up to two weeks to obtain an appeal processing number, please call ahead.
Sincerely,
S.H.I.T Plan Director
M.B.A/C.P.A