| Name | Value |
|---|---|
| NAME | UNAUTHORIZED DISPOSITION |
| TYPE OF LETTER | UNAUTHORIZED CLAIM |
| BEGINNING OF LETTER | We have carefully reviewed your claim for payment of unauthorized medical services. The following decision has been made: |
| END OF LETTER | If you do not agree with the decision you have the right to appeal. Your Sincerely, Chief, Medical Administration Service appeal rights should be attached for your review, if your claim was not approved. If you have any questions concerning this matter, please contact us at the above address. A copy of this letter is being furnished to the provider(s) of care, if applicable. |