Templates Healthcare Medical Requests for Admission - Healthcare Dispute
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REQUESTS FOR ADMISSION - HEALTHCARE DISPUTE

Requests

  1. Admit that the services at issue were provided on [DATE].
  2. Admit that you received the billing statement dated [DATE].
  3. Admit that you denied payment for the services on [DATE].
  4. Admit that the billed codes reflect the services provided.
  5. Admit that the contract governs reimbursement for the services at issue.
  6. Admit that no prior authorization was required for the services.
  7. Admit that you did not request additional documentation before denial.
  8. Admit that you have no evidence the services were medically unnecessary.
  9. Admit that you did not timely appeal or review the denial.
  10. Admit that the amount at issue is $[AMOUNT].

Verification

text
I declare under penalty of perjury that the foregoing responses are true and correct.

______________________________
[RESPONDING PARTY NAME]
Date: [DATE]

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