Free Sample Unpaid Claims Letter
Free Sample Access to Care Letter
Name: ____________________________
Address: ____________________________
____________________________
Subscriber #: _________________________
Phone: ____________________________
Date: ____________________________
Insurance Company: __________________________
Address: __________________________
__________________________
RE: NO QUALIFIED PSYCHIATRIST / PSYCHOTHERAPIST IN NETWORK
Authorization of care department,
I have called all the providers on your list and none are taking new patients and/or do not return the
phone call. If there is no doctor within your plan’s network that meets the qualified health care professional
standard, then the plan must authorize a second opinion from someone with the appropriate qualifications from
outside of the plan’s network, and take into account my ability to travel to the provider.
I am therefore requesting to be reimbursed or have a "single case agreement" set up to see a specialist
outside the panel within 72 hours. Please respond within the three business days as required by law.
Sincerely,
________________________________
(Your Name)
CC: Linder Psychiatric Group, Inc.
Name: ____________________________
Address: ____________________________
____________________________
Subscriber #: _________________________
Phone: __________________________
Date: __________________________
Insurance Company: __________________________
Address: __________________________
__________________________
RE: UNPAID CLAIMS COMPLAINT
Dear Complaint & Claims Departments:
URGENT - The below claim has been filed in accordance with the Provider Procedure Manual, and has not
been paid. You are presently in violation of Health and Safety Code Section 1371 that requires health plans
to pay claims within 45 days.
Procedure Code: 90801, 90806, 90807, 90805, 90862 or (See enclosed unpaid claims)
Date of Service: ________________________________ or (See enclosed unpaid claims)
Please make further action on our part unnecessary by sending payment within ten (10) days of the above
date. If you have any questions, please contact me at (916) ____________________. Thank you in advance
for your prompt attention to this matter.
Sincerely,
________________________________________
(Name)
CC: Linder Psychiatric Corp, Inc.
_______________________________________________________________________________________
Free Sample Access to Care Letter
Name: ____________________________
Address: ____________________________
____________________________
Subscriber #: _________________________
Phone: ____________________________
Date: ____________________________
Insurance Company: __________________________
Address: __________________________
__________________________
RE: NO QUALIFIED PSYCHIATRIST / PSYCHOTHERAPIST IN NETWORK
Authorization of care department,
I have called all the providers on your list and none are taking new patients and/or do not return the
phone call. If there is no doctor within your plan’s network that meets the qualified health care professional
standard, then the plan must authorize a second opinion from someone with the appropriate qualifications from
outside of the plan’s network, and take into account my ability to travel to the provider.
I am therefore requesting to be reimbursed or have a "single case agreement" set up to see a specialist
outside the panel within 72 hours. Please respond within the three business days as required by law.
Sincerely,
________________________________
(Your Name)
CC: Linder Psychiatric Group, Inc.
Name: ____________________________
Address: ____________________________
____________________________
Subscriber #: _________________________
Phone: __________________________
Date: __________________________
Insurance Company: __________________________
Address: __________________________
__________________________
RE: UNPAID CLAIMS COMPLAINT
Dear Complaint & Claims Departments:
URGENT - The below claim has been filed in accordance with the Provider Procedure Manual, and has not
been paid. You are presently in violation of Health and Safety Code Section 1371 that requires health plans
to pay claims within 45 days.
Procedure Code: 90801, 90806, 90807, 90805, 90862 or (See enclosed unpaid claims)
Date of Service: ________________________________ or (See enclosed unpaid claims)
Please make further action on our part unnecessary by sending payment within ten (10) days of the above
date. If you have any questions, please contact me at (916) ____________________. Thank you in advance
for your prompt attention to this matter.
Sincerely,
________________________________________
(Name)
CC: Linder Psychiatric Corp, Inc.
_______________________________________________________________________________________
| Linder Psychiatric Group, Inc. Child, Adolescent, Adult, and Forensic Psychiatry |
Ph: (916) 608-0714
 |  |  |  |  |  |  |  |
| Linder Psychiatric Group, Inc. Child, Adolescent, Adult, and Forensic Psychiatry |