Free Medical Benefit Explanation Letter Design Template
Medical Benefit Explanation Letter Design
[Your Name]
[Your Address]
[Your Email]
[Your Phone Number]
July 2, 2051
Mary Smith
Claims Specialist
MS Health Insurance Company
456 Elm Street
New York, NY 10001
Subject: Explanation of Medical Benefits
Dear Ms. Smith,
I hope this letter finds you in good health and spirits. I am writing to provide a clear and concise explanation of the medical benefits associated with my recent healthcare services under Policy Number XYZ123456.
Medical Benefit Details
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Patient Name: [Your Name]
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Policy/Account Number: XYZ123456
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Service Dates: June 10, 2050 – June 12, 2050
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Claim Number: CLM7891011
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Healthcare Provider: Sunnydale Hospital
The purpose of this letter is to explain the coverage for medical benefits related to my recent hospitalization and the services rendered. This includes treatment for a diagnosed respiratory infection, which requires consultation, X-rays, and prescribed medications.
Coverage Breakdown
The services provided include the following:
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Consultation with Specialist:
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Amount Billed: $250.00
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Amount Covered: $200.00
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Patient Responsibility: $50.00
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Chest X-Ray:
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Amount Billed: $500.00
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Amount Covered: $400.00
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Patient Responsibility: $100.00
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Prescribed Medications:
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Amount Billed: $150.00
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Amount Covered: $120.00
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Patient Responsibility: $30.00
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These benefits are in line with the terms and conditions outlined in my medical benefits plan. Should there be any discrepancies or additional clarification needed, I would be happy to address them promptly.
Supporting Documents
Attached to this letter, please find relevant supporting documents, including:
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Itemized bills from Sunnydale Hospital
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Explanation of Benefits (EOB) form provided by MS Health Insurance
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Receipts for prescribed medications
Contact Information
If you have any further questions or require additional information, please do not hesitate to contact me.
Thank you for your time and understanding. I appreciate your prompt attention to this matter and look forward to resolving it efficiently.
Sincerely,
[Your Name]
