The information furnished does not substantiate the need for this level
excess of any deductible and coinsurance amounts. We will recover the
reimbursement from you as an overpayment
of service. If you believe the service should have been fully covered as
billed, or if you did not know and could not reasonably have been
expected to know that we would not pay for this level of service, or if
you notified the patient in writing in advance that we would not pay for
this level of service and he/she agreed in writing to pay, ask us to
review your claim within 120 days of the date of this notice. If you do
not request an appeal, we will, upon application from the patient,
reimburse him/her for the amount you have collected from him/her in
