RE: Request for Claim Resolution
Member ID: ______________________
Date of Service: ___________________
Please be advised that this letter and enclosed information is in response to your recent denial of a Workers' Compensation claim for patient ______________________.
In accordance with the Texas Workers' Compensation Commission Rule 133.304, Subsections (K), (L), and (M), we are enclosing a copy of the complete medical bill for your reconsideration, copy of the explanation of benefits and a claim specific substantive explanation of why this claim should be reconsidered for reimbursement.
It is our understanding that within 21 days of receiving this request for reconsideration the insurance carrier shall take final action on the claim and that the sender of the claim may request medical dispute resolution with the TWCC if still dissatisfied with (1) the insurance carrier's determination on the claim or, (2) the sender has not received the insurance carrier's response by the 28 th day after the request for reconsideration was sent to the insurance carrier.
We look forward to your prompt review and resolution of this request of reconsideration.
Should you have any questions please contact our office at _____________________.