How to Use the Letter Templates
Send Your Own Letter
- Members can use the Practice Management version to generate responses to insurance carriers.
Ask the ACR to Send a Letter
The ACR sends letters on behalf of members, us with any insurance issues. Please reference the ACR version of mailed letters on behalf of our members.
Members can email drafted letters to Cindy Gutierrez at for ACR approval.
Templates
Members please login to see the members-only version of this page.
+ Procedure Letter Templates
- Procedure Letter Templates
- Consultation Code Denials Template | ACR Version [Dec 2010]
- Bundling 20550 With Other Procedures Template | ACR Version [Jan 2010]
- MRI Letter Template | ACR Version [Mar 2011]
- MSK Procedures Denials Template | ACR Version [Mar 2011]
- VFA Letter Template | ACR Version [no date]
+ Lab
- Lab
- Denial of TB Tests for TNF Template | ACR Version [Mar 2008]
- Hepatitis B and Hepatitis C Denial Letter Template | ACR Version [Mar 2011]
+ Drug Letter Templates
- Drug Letter Templates
- Welborn Health Plans- Rituximab Policy Template | ACR Version [Dec 2010]
- Administration of Abatacept - 90765 Template | ACR Version [Jan 2010]
- BC of PA Denial of Biologics Template | ACR Version [May 2010]
- Coventry HealthCare of GA- Denial of Humira Template | ACR Version [Jun 2010]
- Coventry HealthCare of VA- Infliximab Dosing Guidelines Template ACR Version [Nov 2010]
- CVS Caremark Specialty Drug Policy Template | ACR Version [Oct 2010]
- Denial of Rituximab Template | ACR Version [no date]
- Downcoding Infusions-Actemra-Tocilizumab Template | ACR Version [Mar 2010]
- Equal Access for Humira Template | ACR Version [Mar 2010]
- Humana Step Care Therapy Policies Template | ACR Version [Aug 2010]
- Kansas State Health Plan- specialty drug pilot program Template | ACR Version [Nov 2010]
- Palmetto- certolizumab pegol Template | ACR Version [Jul 2010]
- Regence Actemra Policy Response Template | ACR Version [Apr 2010]
- Regence Colchicine Policy Response Template | ACR Version [Mar 2010]
- Regence Fail First Policies Template | ACR Version [Aug 2010]
- Regence Medical Policy Manual Response Template | ACR Version [Sep 2010]
- Regence Rituxan Policy Response Template | ACR Version [May 2010]
- Trailblazer Ibandronate Template | ACR Version [Mar 2008]
+ E/M Letter Templates
- E/M Letter Templates
Modifier-25 Template | ACR Version [2010]
+ Other Letter Templates
- Other Letter Templates
- Wellmark BCBS failed treatment before prescribing biologics Template | ACR Version [March 2011]
- Accredo Brown Bagging Letter | ACR Version [June 2010]
- BS of NY Prior-Authorization for Prednisone Letter | ACR Version [Mar 2010]
- Frequent Documentation Requests | ACR Version [Feb 2008]
- Horizon BCBS-SubQFirst Template | ACR Version [Mar 2010]
- Trailblazer Documentation Letter Template | ACR Version [Aug 2009]
