My claim was denied
How do I write an appeal letter?
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Keep it short and complete: who you are, what was denied, why the denial reason does not apply, and what you are asking for. Let the attachments do the heavy lifting: the denial letter, the doctor's notes and the plan rule that supports you.
What to do
- Check which level of appeal you are at. Each level has its own format, deadline and reviewer, so the letter changes with it.
- Start with the facts at the top: your name, member ID, claim number, date of service and the date of the denial.
- State in one sentence what you are asking for: that the plan cover the service named in the denial.
- Answer the plan's stated reason directly, using the same words the letter used, and explain why it does not apply to you.
- Attach the proof: the denial letter, a letter from your doctor, the relevant records and the page of your plan document that covers this care.
- Send it the way the letter says (fax, portal or mail), keep a copy, and keep proof of the date it was sent.
What to say
I'm filing a formal internal appeal of this denial. Can you confirm the address or fax number, the deadline, and how I can check that it was received?
Say this on the phone before you send the letter, and write down the name of the person you spoke to.
What to watch out for
This is a sensitive stepSmall details here can change the outcome, and some mistakes are hard to undo. We highly recommend a free 15-minute call with us before you decide.
Writing about how hard this has been instead of answering the reason on the letter. The reviewer is checking one thing, whether the care meets the plan's rule, so give them what they need to say yes.
Better done together
We’re here to help
Every appeal letter is a little different. The format depends on the plan, the kind of denial and the level of appeal. In our experience, letters with too much background can still be turned down; letters that are concise, thorough and backed by the right documents do better.
We help you put the letter and the attachments together so they answer exactly what the reviewer is looking for. Do one with us, and the next one is yours.
Every situation is different, and these are sensitive moments, so we look at yours with care. We often see what others miss, and we never take commissions from insurance companies: the only thing we are working for is what is right for you.
Free · 15 minutes · No pressure
The rule behind it
The Affordable Care Act gives most people with private plans the right to an internal appeal. You usually have 180 days from the denial to file. The plan must decide within 30 days for care you haven't had yet, 60 days for care you already received, and 72 hours for urgent care. Medicare has its own appeal forms and deadlines.
Sources
- HealthCare.gov — Internal appeals
- 29 CFR 2560.503-1 — Claims procedure (Cornell LII)
- Your denial letter and your plan's Evidence of Coverage
Amanda Alcodia
Education, not medical, legal or insurance advice.
Useful next steps
Start with the free Kit. If your situation needs a person, the intro call is free too.