Denial and Appeal Letters

Appendix H

Denial Letter and Appeal Notification

0920-0891

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Enrollment Denial

Re: <Member ID#>

<Date>

Dear <First Name> <Last Name>:

The World Trade Center (WTC) Health Program has reviewed your application for enrollment. After careful consideration of your application, I regret to inform you that we have determined that you are not eligible under the requirements specified in Sections 3311 or 3321 of Title XXXIII of the Public Health Service Act (the James Zadroga 9/11 Health and Compensation Act), 42 U.S.C. §§300mm-21 or 300mm-31.

The determination that you are not eligible was based on the following reason(s):

[Specify reason(s) why applicant was determined not to be eligible].

This determination will become final 60 calendar days from the date of this letter unless you file an appeal.

Appeal Rights

If you believe the denial of eligibility was made in error, you or your representative may appeal the denial by sending a written letter to the Administrator, WTC Health Program, at the following address: WTC Health Program, 327 Columbia Turnpike, Rensselaer, NY 12144.

The letter must be sent within 60 calendar days of the date of this letter. The information you submit with your appeal should include a complete explanation of the specific reasons you feel the denial is incorrect. A copy of your original application is included with this letter. You may include with your appeal letter any relevant information in support of your appeal which was not previously provided to the Administrator of the WTC Health Program.

Please note that all appeal letters must be signed. Your signature indicates that the information you provided is correct to the best of your knowledge. If you have questions about this letter or the appeal process, please send your question to the mailing address provided above or call the WTC Health Program at 1-888-982-4748.

Sincerely,

John Howard, M.D.
Administrator, World Trade Center Health Program

Enclosure:

Overview of the Appeal Process For Denial of Eligibility for Enrollment in the WTC Health Program

Certification Denial – Responder and Certified Eligible Survivor

Re: <Member ID#>

<Date>

Dear <First Name> <Last Name>:

This letter is to inform you that your health condition, [NAME OF HEALTH CONDITION], is not eligible for certification as a [World Trade Center (WTC)-related health condition or health condition medically associated with your certified WTC-related health condition] because your 9/11 exposure is not substantially likely to be a significant factor in aggravating, contributing to, or causing your health condition.

This determination is based upon an assessment of your individual exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the terrorist attacks, as well as the type of symptoms for your condition and the time interval for development of your condition.

 

[INSERT TEMPLATE LANGUAGE]

The WTC Health Program only provides treatment benefits (i.e., medication or health care services) for a health condition that has been certified as either WTC-related or medically associated with a certified WTC-related health condition. Monitoring or treatment benefits for any health conditions that have previously been certified by the WTC Health Program will not be affected by this denial.

This determination will become final 60 calendar days from the date of this letter unless you file an appeal.

Appeal Rights

If you believe the denial of your health condition certification was made in error, you may request to appeal the denial by sending a written letter to the following address or fax:

Appeal Coordinator

WTC Health Program

327 Columbia Turnpike

Rensselaer, NY 12144

Fax: 1.404.471.8338

The appeal request letter must be postmarked or faxed within 60 calendar days of the date of this letter. Your appeal request should include a complete explanation of the specific reasons you feel the denial is incorrect. If you choose to make an oral statement as a part of your appeal and/or you would like to designate an individual to represent you during the appeal process, this information should also be included in your letter. Information about the oral statement and designating a representative can be found in the Overview of the Appeal Process for Denial of Health Condition Certification enclosed with this letter.

Please note that all appeal letters must be signed by you or your representative if you have designated one. Your signature on your appeal request letter indicates that the information provided is correct to the best of your knowledge. Should you have any questions about this letter or the appeal process, please send your questions to [email protected] or call the WTC Health Program at 1-888-982-4748 and ask to speak to the appeal coordinator.

Sincerely,

John Howard, M.D.

Administrator, World Trade Center Health Program

Enclosures:

Overview of the Appeal Process for Denial of Health Condition Certification

Supporting medical information submitted by your WTC Health Program Physician

Certification Denial – Screening Eligible Survivor

Re: <Member ID#>

<Date>

Dear <First Name> <Last Name>:

This letter is to inform you that your health condition, [NAME OF HEALTH CONDITION], is not eligible for certification as a [World Trade Center (WTC)-related health condition or health condition medically associated with your certified WTC-related health condition] because your 9/11 exposure is not substantially likely to be a significant factor in aggravating, contributing to, or causing your health condition.

This determination is based upon an assessment of your individual exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the terrorist attacks, as well as the type of symptoms for your condition and the time interval for development of your condition.

 

[INSERT TEMPLATE LANGUAGE]

As a result, I regret to inform you that you are not eligible for status as a certified-eligible survivor under the requirements specified in Section 3321(a)(2) of Title XXXIII of the Public Health Service Act (the James Zadroga 9/11 Health and Compensation Act of 2010), 42 U.S.C. §§300mm-31. Please note, you remain enrolled in the WTC Health Program as a screening-eligible survivor and do not need to re-apply for enrollment. However, only certified-eligible survivors are eligible for monitoring and treatment by the WTC Health Program. Screening-eligible survivors only receive their initial health evaluation at no cost to them. If you want a second health evaluation in the future, you will be personally responsible for the cost of any additional health evaluations at a WTC Health Program participating medical facility.

This determination will become final 60 calendar days from the date of this letter unless you file an appeal.

Appeal Rights

If you believe the denial of your health condition certification was made in error, you may request to appeal the denial by sending a written letter to the following address or fax:

Appeal Coordinator

WTC Health Program

327 Columbia Turnpike

Rensselaer, NY 12144

Fax: 1.404.471.8338

The appeal request letter must be postmarked or faxed within 60 calendar days of the date of this letter. Your appeal request should include a complete explanation of the specific reasons you feel the denial is incorrect. If you choose to make an oral statement as a part of your appeal and/or you would like to designate an individual to represent you during the appeal process, this should also be included in your letter. Information about the oral statement and designating a representative can be found in the Overview of the Appeal Process for Denial of Health Condition Certification enclosed with this letter.

Please note that all appeal letters must be signed by you or your representative if you have designated one. Your signature on your appeal request letter indicates that the information provided is correct to the best of your knowledge. Should you have any questions about this letter or the appeal process, please send your questions to [email protected] or call the WTC Health Program at 1-888-982-4748 and ask to speak to the appeal coordinator.

Sincerely,

John Howard, M.D.

Administrator, World Trade Center Health Program

Enclosures:

Overview of the Appeal Process for Denial of Health Condition Certification

Supporting medical information submitted by your WTC Health Program Physician

Treatment Denial

Re: <Member ID#>

<Date>

Dear <First Name> <Last Name>:

This letter is to inform you that a specific treatment for your certified health condition [NAME OF HEALTH CONDITION] has been determined not to be medically necessary. The treatment has been determined not to be medically necessary because [REASONS]. The World Trade Center (WTC) Health Program will not provide any benefits associated with this specific treatment of your certified health condition.

This determination will become final 60 calendar days from the date of this letter unless you file an appeal.

Appeal Rights

If you believe the denial of treatment benefits was made in error, you or your representative may appeal the denial by sending a written letter to the Administrator, WTC Health Program, at the following address: WTC Health Program, 327 Columbia Turnpike, Rensselaer, NY 12144.

The letter must be sent within 60 calendar days of the date of this letter. The information you submit with your appeal should include a complete explanation of the specific reasons you feel the denial is incorrect.

Please note that all appeal letters must be signed. Your signature indicates that the information you provided is correct to the best of your knowledge. If you have questions about this letter or the appeal process, please send your question to the mailing address provided above or call the WTC Health Program at 1-888-982-4748.

Sincerely,

John Howard, M.D.

Administrator, World Trade Center Health Program

Copy to: Director, Clinical Center of Excellence