[Your letterhead, if desired; if not, your return address]
[Date of letter-month, day, and year]
[Recipient's first and last names]
[Street or P.O. box address]
[City, State ZIP code]
Dear [recipient's name]:
We have received your recent claim for Medicare coverage under your existing policy for a doctor visit and prescription. Unfortunately, we must deny this claim, because the doctor and pharmacy that provided the services and care are not participating Medicare providers. We are enclosing a listing of your local Medicare providers so that you can save money by consulting them in the future. You can also request that your current providers become Medicare participating providers. Inquire at your doctor's office and pharmacy about this.
Thank you for sending this claim to us, and we regret that we must deny it. Please contact us if you have any additional questions regarding this claim.
[Sender's first and last names]