Document text
[YOUR FULL NAME]
[STREET ADDRESS]
[CITY, STATE ZIP]
[PHONE] · [E-MAIL]
[DATE]
SENT BY [CERTIFIED MAIL / FAX / ONLINE FORM] — use the address given in your final denial notice
[EXTERNAL REVIEW CONTACT — the plan, your state insurance department, or the federal external review process, as stated in the notice]
[ADDRESS]
Re Request for [EXPEDITED / STANDARD] external review
Member · patient [MEMBER NAME] · [PATIENT NAME], born [DATE OF BIRTH]
Health plan · member ID [PLAN OR INSURER] · [MEMBER ID] · group [GROUP NUMBER]
Plan type [EMPLOYER PLAN — INSURED / SELF-FUNDED] / [INDIVIDUAL OR MARKETPLACE PLAN] / [UNKNOWN]
Final denial dated [DATE], received [DATE] · reference [NUMBER]
Service, drug or item [DESCRIPTION, CODES] · [DATE(S) OF SERVICE / “NOT YET RECEIVED”]
Treating provider [NAME, PHONE]
To the External Review Unit:
I request an independent external review of [PLAN NAME]’s final internal adverse benefit determination dated [DATE], which denied [SERVICE, DRUG OR ITEM] for [PATIENT NAME]. This request is filed within four months after I received that determination.
[IF URGENT — KEEP; OTHERWISE DELETE:] I request an expedited external review. [DOCTOR’S NAME] certifies that the time for a standard review would seriously jeopardize the patient’s life, health or ability to regain maximum function [/ the denial concerns an admission, availability of care, continued stay or service for which the patient received emergency services and has not been discharged]. The doctor’s statement is enclosed.
Why this denial can be reviewed
1. The denial involves medical judgment — [MEDICAL NECESSITY / APPROPRIATENESS / HEALTH CARE SETTING / LEVEL OF CARE / EFFECTIVENESS / EXPERIMENTAL OR INVESTIGATIONAL] — [or it is a rescission of coverage].
2. I completed the plan’s internal appeal on [DATE] [/ the plan did not follow the claims and appeals rules, so the internal appeal is deemed exhausted: EXPLAIN].
Why the denial is wrong
[SUMMARIZE IN A FEW PARAGRAPHS: the diagnosis, what the doctor prescribed and why, what was tried before, what the plan document says, and where the plan’s reasons are mistaken. Refer to the enclosed evidence by number.]
Enclosed:
1. The final internal denial and the first denial notice;
2. My internal appeal letter dated [DATE];
3. Letter of medical necessity from [DOCTOR], dated [DATE];
4. [MEDICAL RECORDS, TEST RESULTS, STUDIES OR GUIDELINES];
5. [PLAN DOCUMENT PAGES];
6. [SIGNED AUTHORIZATION TO RELEASE MEDICAL RECORDS / EXTERNAL REVIEW FORM — if required];
7. [AUTHORIZED REPRESENTATIVE FORM — if someone files for the patient].
Please confirm receipt and tell me which independent review organization is assigned. I understand the decision is due within 45 days after the organization receives the request (72 hours for an expedited review).
Sincerely,
______________________________ [YOUR FULL NAME] [MEMBER / PATIENT / AUTHORIZED REPRESENTATIVE]
NOTES — delete this page before sending
• Deadline: four months after you receive the final denial. If there is no matching date four months later, the last day is the first day of the fifth month (e.g. notice received October 30 → March 1). If that day is a Saturday, Sunday or federal holiday, it moves to the next business day (45 CFR 147.136(d)(2)(i), federal process). State processes must allow at least four months (147.136(c)(2)(vi)).
• Which process applies — your state’s or the federal one — is stated in the final denial notice. Self-funded employer plans generally use the federal process; insured plans and individual policies usually use the state process.
• Decision: within 45 days after the independent review organization receives the request; expedited — as fast as the medical situation requires and no later than 72 hours. Some states charge a filing fee of no more than $25, refunded if you win.
• Scope: denials that involve medical judgment, and rescissions of coverage. Purely contractual or eligibility denials may not qualify.
• If you win, the plan must provide the coverage or payment. Keep copies of everything and proof of the dates.
Fields in [SQUARE BRACKETS] must be completed or deleted. © Layers (layers.md), licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is a template with deadlines taken from federal rules; it is not legal or medical advice. Your plan documents and denial notice govern your case; state rules and some plan types (Medicare, Medicaid, government and church plans) differ.
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Template — not legal or medical advice. Check your plan documents and denial notice. © Layers (layers.md) · CC BY 4.0