# Claim Appeal Letter Template for Denied NEMT Trips, With an Exhibit List

Canonical URL: https://nemtguide.com/templates/claim-appeal-letter/ · Updated 2026-10-02

A claim appeal letter asks the payer that denied your NEMT claim to reverse the decision and pay. Name the claim, rider, date of service, and denial code, explain in plain facts why the denial is wrong, and state the amount you want. Attach numbered proof: the remittance, trip log, signature, mileage record, authorization, and eligibility check. Send it inside the payer's window, with proof of delivery.

- Appeal only when the payer got it wrong. When the error was yours, send a corrected claim instead.
- Use the payer's own format where it has one: Medi-Cal's Appeal Form 90-1, South Dakota's portal, MTM Health's claims portal, or an Indiana letter marked "Claim Administrative Review."
- Answer the denial code directly, name the rule, and ask for a dollar amount. Arizona denies disputes that lack specificity.
- Number every exhibit and refer to it in the letter. Indiana upholds a denial when the documents to support the request are missing.
- Keep proof of delivery and a full copy, and never bill the rider while the appeal is open.

A denied trip is a ride you already gave. When the payer got it wrong, a short, specific letter with the right proof attached is how you get paid for it. This template gives you the letter, a numbered exhibit list, and openings for the three payers a NEMT company deals with: the state, a health plan, and a broker.

## How to use this template

1. **Make sure an appeal is the right fix.** If the denial came from your own mistake, such as a wrong Medicaid ID, modifier, or mile count, send a corrected claim instead. Indiana tells providers to correct and resubmit through routine claim channels first, and to ask for an administrative review only after reasonable attempts to fix the claim. See [corrected NEMT claims](https://nemtguide.com/guides/corrected-nemt-claims/).
2. **Find who denied it and the last day to file.** Look at who sent the remittance: the state's claims contractor, a health plan, or a broker. Each sets its own window, and many count from the remittance date. [How to appeal a denied Medicaid claim](https://nemtguide.com/guides/appeal-denied-nemt-claim/) lists the deadlines for several payers, and your [claim denial log](https://nemtguide.com/templates/claim-denial-log/) should already show the date.
3. **Check whether the payer wants its own form or portal.** Some accept a letter. Others take only a form or a portal entry. The next section lists what several payers require. When a portal is the only way in, paste the letter's paragraphs into its comment box and upload the exhibits.
4. **Write one letter per claim and one rider per letter.** Texas wants one claim circled on each remittance page, and Medi-Cal wants only one rider on each appeal form.
5. **Fill in Part 1, then the letter in Part 2.** Copy the codes exactly as the remittance prints them. Keep the letter to one page: the facts, the rule, and the amount.
6. **Build the exhibits in Part 3.** Number each one, mark the denied line on the remittance, and refer to each exhibit by number in the letter.
7. **Sign it.** Medi-Cal returns appeals that are not signed by the provider or an authorized representative.
8. **Send it with proof, and record it in Part 5.** Keep the portal confirmation, fax report, or certified mail receipt, and a full copy of everything you sent.
9. **Check the next remittance.** Medi-Cal and Arizona both say a claim approved on appeal still goes through normal processing and can deny for a different reason.

## The template

### Part 1: Claim details

| Field | Write it here |
|---|---|
| Your company's legal name, address, and phone | |
| NPI, and Medicaid or broker provider number | |
| Payer, office, and where this goes (address, fax, or portal) | |
| Rider's name and Medicaid ID | |
| Date of service, and trip ID or authorization number | |
| Payer's claim number, and earlier claim numbers for this trip | |
| Amount billed, amount paid, and amount you are asking for | |
| Reason and remark codes, and the remittance date | |
| Last day the payer will accept this, and the rule that sets it | |
| Who at your company handles it, with a direct phone number | |

### Part 2: The letter

[Your letterhead]

Date: ______________

To: ______________________________ (payer, office, and mailing address or portal)

Re: ______________________________ (the payer's name for this request, such as Claim Administrative Review, appeal, reconsideration, or claim dispute) for claim number ______________

Rider: ______________ Medicaid ID: ______________ Date of service: ______________ Trip ID or authorization number: ______________

Provider: ______________ NPI: ______________ Provider number: ______________

**What we ask.** Please review claim number ______________ and pay $______________ for the trip above. You denied it on the remittance dated ______________ with reason code ______ and remark code ______.

**What happened.** On ______________, our driver picked up the rider at ______________ at ______ and dropped the rider off at ______________ at ______ for a covered visit with ______________. The trip was ______ loaded miles, recorded by [odometer readings / a mapping record]. It was authorized under number ______________, issued on ______________. The rider was eligible on the date of service (Exhibit ______).

**Why the denial is wrong.** The denial says ______________________________. That is not correct because ______________________________. Your [provider manual / our agreement], section ______________, says ______________________________.

**What we already tried.** [We sent a corrected claim on ______________, claim number ______________.] [We called on ______________ at ______ and spoke with ______________, reference number ______________.]

**Proof.** The exhibits listed below support each statement above. Please contact ______________ at ______________ with any question.

Signature: ______________________________ Printed name and title: ______________________________ Date: ______________

### Part 3: Exhibit list

| No. | Exhibit | What it proves | Pages | Attached |
|---|---|---|---|---|
| 1 | Remittance page, with the denied line marked | The decision, its codes, and its date | | |
| 2 | The claim as billed, and any corrected claim | What you billed and when | | |
| 3 | Trip log or driver's ticket | Pickup, departure, and arrival times, the driver, and the vehicle | | |
| 4 | Rider's signature, or who signed and why | The rider took the ride | | |
| 5 | Odometer readings or mapping record | Loaded miles by the shortest route | | |
| 6 | Authorization or trip assignment | The trip, date, and level of service were approved | | |
| 7 | Eligibility check for the date of service | The rider was covered that day | | |
| 8 | Proof of timely filing | Acceptance reports, claim status responses, or earlier letters from the payer | | |
| 9 | Driver and vehicle credentials | Both were approved on the date of service | | |
| 10 | Facility signature or visit record | The rider went to a covered visit | | |
| 11 | Call record | Date, time, and the name or ID of the payer's representative | | |
| 12 | Other | | | |

### Part 4: Openings by who denied the claim

Start with the opening that fits, then use the "What happened" through "Proof" paragraphs from Part 2.

**To the state Medicaid agency or its claims contractor.** Re: [Claim Administrative Review / appeal / claim dispute], claim number ______________. [Company], NPI ______________, asks for review of this fee-for-service claim for date of service ______________, denied on the remittance dated ______________ with code ______. The claim should pay because ______________________________. We ask for payment of $______________.

**To a Medicaid health plan.** Re: Provider claim dispute, claim number ______________, under section ______________ of your provider manual. [Company] is the billing provider and disputes your decision on its own claim for member ______________, ID ______________, date of service ______________. The claim should pay because ______________________________. We ask for payment of $______________.

**To a broker.** Re: Claim appeal, trip ID ______________, claim number ______________. Under section ______________ of our transportation provider agreement, [Company] appeals your denial of this trip on ______________. The trip was assigned to us, completed, and documented as shown in Exhibits ______. We ask for payment of $______________ at the agreement's rate.

### Part 5: Sending record

| Date sent | How sent (portal, fax, mail, hand) | Confirmation or tracking no. | Date the payer received it | Answer expected by | Result and next deadline |
|---|---|---|---|---|---|
| | | | | | |
| | | | | | |
| | | | | | |

## Formats some payers require

Write the letter once, then fit it to the payer. Each of these rules comes from the payer's own manual.

- **Indiana fee-for-service (claim review module version 7.1, March 24, 2026).** Use a secure message in the IHCP Provider Healthcare Portal under the Claim Administrative Review Request category, the IHCP Claim Administrative Review Request form, or a letter on letterhead with "Claim Administrative Review" printed on its face. Give the claim ID, the IDs of earlier attempts, and a detailed reason. Attach what the claim originally required and any proof of timely filing. A completed claim form is optional but speeds payment if you win. Mail goes to Gainwell Written Correspondence, PO Box 50442, Indianapolis, IN 46250-0418, within 60 calendar days of the most recent remittance. Receipt is confirmed within 10 business days, and the decision comes within 45 calendar days.
- **Indiana trips decided by Verida.** These do not go through the state's review. Ask for an administrative review through the help desk option in the Verida Provider Portal. If that does not settle it, send a written appeal to Claim Appeals, Verida Claims, 843 Dallas Highway, Villa Rica, GA 30180 (transportation module version 6.1, August 19, 2025). This applies whether or not you have a contract with [Verida](https://nemtguide.com/brokers/verida/).
- **Medi-Cal fee-for-service.** Any written complaint that identifies the claim and describes the disputed action starts an appeal, but the Appeal Form (90-1) is the simplest way. Boxes 3, 4, 5, 7, 8, 10, 11, and 12 are required, and the denial code from the remittance goes in Box 12. The reason goes in Box 13, or check a common reason in Box 14, and the form must be signed. Mail it to Attn: Appeals Unit, California MMIS Fiscal Intermediary, P.O. Box 15300, Sacramento, CA 95851-1300, within 90 days of the action (manual pages updated through October 2025).
- **Arizona AHCCCS fee-for-service (Chapter 28, revised November 19, 2025).** A claim dispute must be in writing and state in detail the factual and legal basis and the relief you want, such as payment. Mail it to the Office of the General Counsel, PO Box 6050, Phoenix, AZ 85005, deliver it to 150 N 18th Ave, Phoenix, AZ 85007, fax it to (602) 253-9115, or file it in the AHCCCS Online Provider Portal. If you relied on something a claims representative told you by phone, give the date, the approximate time, and the representative's name or operator number.
- **Texas Medicaid claims to TMHP (Section 7, September 2026).** Appeal electronically, through the Automated Inquiry System, or on paper. A paper appeal is a copy of the R&S Report page with one claim circled, the reason, the incorrect and corrected information, and supporting documents on separate pages. Mail it to Texas Medicaid & Healthcare Partnership, Appeals/Adjustments, PO Box 200645, Austin, TX 78720-0645. TMHP must receive it within 120 days of the R&S Report date. Demand response providers in the Medical Transportation Program can also send appeals through TexMedConnect, TMHP's free claims website (MTP handbook, September 2026).
- **South Dakota Medicaid (manual updated February 2025).** Reconsiderations go only through the Medicaid Portal, under Communications, then Reviews and Requests. For most NEMT denials choose Other Claim Reconsideration Review. In the Comment-Provider box, say why you dispute the denial, cite the coding standard that supports you, and describe each attachment. You can add up to five attachments of 10 MB each. File within 6 months of the date of service or 3 months of the denial, and expect an answer within 30 days in most cases.
- **MTM Health, Virginia Medicaid fee-for-service (handbook approved August 10, 2026).** Appeal in MTM's online claims portal within 365 calendar days of the denial, with the correct information that answers the reason for denial. Paste the "What we ask" and "Why the denial is wrong" paragraphs into the portal and upload the exhibits. See [MTM Health](https://nemtguide.com/brokers/mtm-health/).

Health plans set their format in their provider manuals. Indiana requires each of its managed care plans to have a formal procedure for providers to request reconsideration of claim decisions. Texas sends appeals of managed care claims to the plan, and Arizona sends disputes for members enrolled in a plan to that plan.

## What a reviewer needs to say yes

Reviewers decide on what the letter and exhibits show, so build both around the denial code.

- **Answer the code you were given.** A denial for a missing authorization needs the authorization. A mileage cut needs the odometer readings or mapping record. Indiana requires mileage on the driver's ticket by odometer readings or mapping software, and a mapping record must show the shortest route. Read the code first with [NEMT claim denials](https://nemtguide.com/guides/nemt-claim-denials/) and [claim adjustment reason codes](https://nemtguide.com/glossary/claim-adjustment-reason-codes/).
- **Be specific.** Arizona denies claim disputes that lack specificity. South Dakota denies reconsiderations without supporting documentation, and Indiana upholds the denial when the documents needed to support the request are missing.
- **Ask for a number.** Name the relief: the full billed amount, a mileage line at the fee schedule rate, or the difference on an underpaid claim.
- **Prove timely filing with the payer's own records.** Texas says your internal notes and logs cannot prove timely filing in an appeal to its Health and Human Services Commission. Medi-Cal accepts only a remittance, a Claims Inquiry Acknowledgment or Response Letter, or another dated letter from its claims contractor, carrying a control number dated within the six-month billing limit. The [claim denial log](https://nemtguide.com/templates/claim-denial-log/) lists what Indiana accepts.
- **Send only what the reviewer needs.** One rider per letter, and only that rider's records. See [NEMT trip documentation](https://nemtguide.com/guides/nemt-trip-documentation/) for what a complete trip record holds.

## Your dispute, not the rider's appeal

A health plan's denial can open two different cases. Federal rules call a plan's denial of payment for a service, in whole or in part, an adverse benefit determination (42 CFR 438.400). The rider can appeal it within 60 calendar days of the notice, and a provider may file for the rider only with the rider's written consent, and only if state law allows it (42 CFR 438.402). A payment denied only because the claim was not a [clean claim](https://nemtguide.com/glossary/clean-claim/) is not an adverse benefit determination.

Keep this letter on your own route. Sign it as the company, under the plan's provider dispute process and your contract, never in the rider's name. With a broker, your appeal runs under your transportation provider agreement. MTM Health's standard agreement, in the January 1, 2023 version Pennsylvania posts, says its appeals process lets providers appeal any denied claim, and that MTM may recover overpayments by offsetting future payments.

Some brokers fall outside the rider's appeal rules altogether. A broker that contracts with the state for NEMT only, paid by capitation or another method that does not use state plan rates, is a NEMT PAHP, and those rules do not apply to it, though its riders keep the right to a state fair hearing (42 CFR 438.402(a) and 438.9). See [prepaid ambulatory health plan](https://nemtguide.com/glossary/prepaid-ambulatory-health-plan/).

## Do not bill the rider while you wait

A denied claim stays between you and the payer. Federal rule [42 CFR 447.15](https://www.ecfr.gov/current/title-42/section-447.15) limits Medicaid to providers who accept the agency's payment, plus any cost sharing the state plan requires, as payment in full. MTM Health's standard agreement bars billing a member even when MTM or its client does not pay, apart from a copayment or fee MTM or its client authorizes. The same agreement pays nothing for trips by drivers, attendants, or vehicles that were not credentialed, which is why Exhibit 9 matters.

If the appeal fails, the next step is the payer's next level, such as a hearing, not the rider. [How to appeal a denied Medicaid claim](https://nemtguide.com/guides/appeal-denied-nemt-claim/) covers hearings and escalation for each payer above.

## Frequently asked questions

### What should a claim appeal letter for a denied NEMT trip include?

Your company name, NPI, and Medicaid or broker provider number; the rider's name and Medicaid ID; the date of service, trip ID, and claim number, with the numbers of any earlier attempts; the denial codes and remittance date; a short statement of why the denial is wrong; the payment you want; a numbered exhibit list; and a signature. Arizona also asks you to spell out the factual and legal basis.

### Can I send a letter instead of the payer's appeal form?

Often, but check first. Indiana accepts a letter on letterhead marked "Claim Administrative Review," a portal message, or its own form. Medi-Cal accepts a written complaint that identifies the claim, though its Appeal Form 90-1 is the simplest route. South Dakota takes reconsiderations only in its Medicaid Portal, and MTM Health in Virginia takes appeals in its claims portal, so there the letter becomes the text you paste in.

### How long do I have to send a NEMT claim appeal?

It depends on the payer. Indiana allows 60 calendar days from the remittance date, Medi-Cal 90 days from the action, Texas Medicaid 120 days from the R&S Report date, and South Dakota 6 months from the date of service or 3 months from the denial. MTM Health in Virginia allows 365 calendar days. The appeal guide lists more payers and when each clock starts.

### Should I send the trip log and signature with my appeal?

Yes, when the denial is about the trip itself. Send the pages that answer the denial reason, such as the driver's ticket with times, the rider's signature, and odometer readings or a mapping record. Indiana requires mileage on the driver's ticket by odometer readings or mapping software, and MTM Health in Virginia denies claims whose trip log lacks the trip ID, the pickup, departure, and arrival times, or the rider's signature.

### Can I file the appeal in the rider's name?

Only on the rider's own appeal, and only with consent. When a Medicaid health plan denies payment for a service, federal rule 42 CFR 438.402 gives the rider 60 calendar days to appeal, and a provider may file for the rider with the rider's written consent if state law allows it. For your own unpaid claim, use the plan's provider dispute process and sign as the company.

### Do I need to send my appeal by certified mail?

Not always, but you need proof of when it arrived. Texas recommends certified mail with a return receipt and a detailed list of the claims enclosed, so you can prove you met its 120-day deadline. Arizona counts the day its Office of the General Counsel receives a dispute as the filing date. Portal confirmations and fax reports work too. Keep a full copy of what you sent.

## Official resources

- [Indiana Medicaid: Claim Administrative Review and Appeals module](https://www.in.gov/medicaid/providers/files/modules/claim-administrative-review-and-appeals.pdf)
- [Medi-Cal: Appeal Form (90-1) instructions](https://mcweb.apps.prd.cammis.medi-cal.ca.gov/file/manual?fn=appealform.pdf)
- [AHCCCS: Chapter 28, Claim Disputes](https://www.azahcccs.gov/PlansProviders/Downloads/FFSProviderManual/FFS_Chap28ClaimDisputes.pdf)
- [TMHP: Section 7, Appeals (paper, electronic, and second-level appeals)](https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-09-september/1_07_appeals.pdf)
- [South Dakota Medicaid: Reconsideration Reviews manual (portal steps)](https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Provider_Basics/Reconsideration_Reviews.pdf)
- [eCFR: 42 CFR Part 438, Subpart F, Grievance and appeal system](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-F)
- [MTM Health: Virginia NEMT provider handbook (claims and appeals)](https://www.mtm-inc.net/wp-content/uploads/2018/12/VA-Provider-Handbook-2026.pdf)