Sample Letter: Workers' Comp/Reply to Carrier

Sample Letter: Workers' Comp/Reply to Carrier for More Information on an Incomplete Claim or More Documentation for a Retrospective Review

RE: Request for Appeal

Patient: _________________________

Member ID: ______________________

Insured: _________________________

Date of Service: ___________________

Amount: _________________________

Dear Payor:

Please be advised that this letter and enclosed information is in response to your request for more documentation on a claim for patient ______________________________.


In accordance with the Texas Workers' Compensation Commission Rules 133.300, the insurance carrier shall evaluate each medical claim for completeness and either return or request by telephone, fax or electronic transmission that information which would make the bill complete as defined in Commission Rule 133.1 (a). A request for information to "fix" an incomplete claim must be make by the insurance carrier within 7 days after it receives the incomplete claim. If unable to correct the claim the insurance carrier may return the claim as incomplete and the sender may correct the incomplete claim and resubmit it to the insurance carrier as a new bill.


In accordance with Rule 133.301 the insurance carrier performing a retrospective review can request any additional documentation, records or information related to the treatment(s) and/or service(s) rendered or charges billed. This type of request by the carrier shall be make not later than the 14 th day after receipt of the claim and must be provided by the sender no later than the 14 th day after receipt of the request.

It is important to note that even thought the sender or health care provider fails to timely provide an insurance carrier with additional documentation it does not extend the amount fo time the insurance carrier has to make payment or deny payment on a claim (45 days).

We look forward to your prompt review and resolution of this claim in accordance with the time frames established by the TWCC Rules in Chapter 133. Benefits-Medical Benefits.

Should you have any questions please contact our office at _______________________.

Last Updated On

June 15, 2011

Originally Published On

March 23, 2010