Decertification Letter and Appeal Notification - Health

WTC Health Program

PO Box 7002

Rensselaer, NY 12144

Name

Address

Address

Re: 911XXXXXX <Date>

Dear (Insert Member Name):

This letter is to inform you that your health condition, (Insert Condition), is not eligible for certification as a World Trade Center (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.

The request for certification of your condition, (Insert Condition), is denied because information submitted by your Clinical Center of Excellence (CCE) or Nationwide Provider Network (NPN) physician about the duration of your 9/11 exposure, together with information about your 9/11 exposure activity (Insert Activity), and the timeframe in which the activity occurred (Insert Timeframe), is not sufficient to establish that your 9/11 exposure is substantially likely to be a significant factor in the development of your health condition.

In addition, the letter you received dated (Insert Date) from the World Trade Center (WTC) Health Program was sent to you in error. The letter indicated that the WTC Health Program had certified your (Insert Condition). Unfortunately, after reviewing your case, the WTC Health Program has determined that this letter was sent to you through an administrative error, as the duration of your 9/11 exposure, as detailed above, is not sufficient to establish that your 9/11 exposure is substantially likely to be a significant factor in the development of your health condition.

We apologize for the inconvenience this error may have caused. The WTC Health Program has updated your member record accordingly to reflect that you are not certified, and thus has decertified the following condition:

Date of Certification	Condition Category on List of WTC-Related Health Conditions*	Certification Category or Injury
(Effective Date)	(Insert Zadroga Term)	(Insert Health Condition)

Regarding the denial of the condition, (Insert Health Condition), this determination will become final 120 calendar days from the date of this letter unless you file an appeal. In addition, coverage for the condition, (Insert Health Condition), will be terminated 120 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, (Insert Condition), and/or the decertification of your (Insert Condition) condition was made in error, you may request to appeal the denial/decertification by sending a written letter to the following address or fax:

Appeal Coordinator

WTC Health Program

P.O. Box 7000

Rensselaer, NY 12144

Fax: 1.877.646.5308

The appeal request letter must be postmarked or faxed within 120 calendar days of the date of this letter. Your appeal request should include a complete explanation of the specific reasons you feel the denial/decertification 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 Monday through Friday, 9 AM to 5 PM (Eastern Standard Time), 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