Health Insurance Appeal Letter (Internal Appeal)

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[YOUR FULL NAME]

[STREET ADDRESS]

[CITY, STATE ZIP]

[PHONE] · [E-MAIL]

[DATE]

SENT BY [CERTIFIED MAIL, RETURN RECEIPT No. [NUMBER] / FAX TO [NUMBER] / THE PLAN’S MEMBER PORTAL]

[APPEALS DEPARTMENT — use the address in your denial notice]

[NAME OF HEALTH PLAN OR INSURER]

[ADDRESS]

Re Request for [EXPEDITED / STANDARD] internal appeal

Member · patient [MEMBER NAME] · [PATIENT NAME, IF DIFFERENT], born [DATE OF BIRTH]

Member ID · group number [MEMBER ID] · [GROUP NUMBER]

Claim or reference number [CLAIM / PRIOR AUTHORIZATION / REFERENCE NUMBER]

Service, drug or item [DESCRIPTION, CPT/HCPCS OR DRUG NAME AND DOSE] · date(s) of service [DATE]

Provider [DOCTOR OR FACILITY, NPI IF KNOWN]

Denial notice dated [DATE], received [DATE] · denial code / reason: [CODE]

Dear Appeals Reviewer:

I am appealing [PLAN NAME]’s decision to deny [COVERAGE OF / PAYMENT FOR / PRIOR AUTHORIZATION OF] [SERVICE, DRUG OR ITEM] for [PATIENT NAME]. The denial notice states: “[COPY THE REASON EXACTLY AS WRITTEN]”. I ask that the decision be reversed.

[IF URGENT — KEEP; OTHERWISE DELETE:] I request an expedited (urgent) appeal. [DOCTOR’S NAME] has determined that waiting for a standard decision could seriously jeopardize [PATIENT NAME]’s life, health or ability to regain maximum function [or would subject the patient to severe pain that cannot be adequately managed without the care]. A decision on an urgent appeal is due within 72 hours.

Why the denial should be reversed

[KEEP THE POINTS THAT APPLY AND STATE THE FACTS:]

1. Medically necessary. [DOCTOR’S NAME] prescribed [SERVICE/DRUG] because [DIAGNOSIS AND CLINICAL REASONS]. The enclosed letter of medical necessity and records explain why it is needed and why alternatives are not appropriate.

2. Covered by my plan. Section [NUMBER/TITLE] of my [SUMMARY PLAN DESCRIPTION / EVIDENCE OF COVERAGE], page [PAGE], covers [WHAT IT SAYS].

3. Other treatments were tried. [PATIENT NAME] tried [DRUGS/TREATMENTS] from [DATES], which [DID NOT WORK / CAUSED SIDE EFFECTS: DESCRIBE].

4. Prior authorization was obtained / requested on time. Authorization [NUMBER] was [GRANTED / REQUESTED] on [DATE].

5. Billing or coding error. The claim was denied as [REASON]; the provider has sent a corrected claim on [DATE] [with code [CODE]].

6. No suitable in-network provider. [EXPLAIN — e.g., the nearest in-network specialist is [DISTANCE] away / has no appointment before [DATE]].

7. [OTHER REASON].

What I ask

1. Reverse the denial and [COVER / PAY THE CLAIM FOR] [SERVICE, DRUG OR ITEM].

2. Send me, free of charge, copies of all documents, records and other information relevant to my claim, including any internal rule, guideline, protocol or criterion relied on, and identify the medical or vocational experts whose advice was obtained (29 CFR 2560.503-1(h)(2)(iii), (h)(3)(iii)–(iv)).

3. Have the appeal decided by a person who did not make the first decision, in consultation with a health care professional with appropriate training and experience in [SPECIALTY].

4. Decide within the time limits: 72 hours for an urgent appeal, 30 days for care not yet received, 60 days for care already received. If the denial is upheld, explain the specific reasons and how to request an external review.

Enclosed: copy of the denial notice; letter of medical necessity from [DOCTOR]; [MEDICAL RECORDS, TEST RESULTS, PRESCRIPTION HISTORY]; [PLAN PAGES]; [AUTHORIZED REPRESENTATIVE FORM — if someone appeals for the patient].

Thank you for your prompt review. Please contact me at [PHONE] or [E-MAIL].

Sincerely,

______________________________ [YOUR FULL NAME] [MEMBER / PATIENT / AUTHORIZED REPRESENTATIVE OF [PATIENT NAME]]

cc: [DOCTOR’S NAME AND PRACTICE]

NOTES — delete this page before sending

• Deadline to appeal: at least 180 days after you receive the denial notice (29 CFR 2560.503-1(h)(3)(i); applied to non-grandfathered group and individual coverage by 45 CFR 147.136(b)). Your plan may allow longer — the notice states the date. Send the appeal well before it and keep proof of delivery.

• Decision on the appeal (group health plans with one level of appeal): urgent — 72 hours after the plan receives it; pre-service — 30 days; post-service — 60 days (29 CFR 2560.503-1(i)(2)). Plans with two levels of appeal have shorter periods for each level.

• After a final denial you can ask for an independent external review — within 4 months after you receive the final denial (45 CFR 147.136). Use the template “External Review Request Letter”.

• Medicare, Medicare Advantage, Medicaid, federal employee (FEHB), TRICARE and VA coverage, and some church or grandfathered plans follow other appeal rules and deadlines — check your notice.

• Ask your doctor for a letter of medical necessity: diagnosis, treatment history, why this service is needed now, and the guideline or evidence it follows. Your state insurance department’s consumer assistance program can help for free.

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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