Knowledge Center
When you disagree with a decision your insurance company makes about your care, you have a right to appeal it. Here’s what you need to know about preparing for that process and writing a clear appeal letter.
What is an appeal?
An appeal is simply a formal request to have your insurance company review a decision about your coverage or care.
Sometimes, a claim is denied because of a mistake, like a missing form. Other times, your insurance company may need more details from your doctor about why a treatment is needed. When you file an appeal, you’re asking your insurance to take a second look at your case.
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Situations when you can typically appeal
You can ask for an appeal on almost any decision your insurance makes that prevents you from getting specific care or causes you to have to pay for it yourself. Here are common situations that could lead to a health care appeal:
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Medical necessity
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Your insurance might say that a type of care or treatment is not medically needed. Your doctor can help you explain why the treatment is important for your health.
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Prior authorization problems
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Some treatments need approval before you get them. This is known as prior authorization. If this request is denied, you can appeal.
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Out-of-network care
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If you saw a doctor who wasn’t in your plan’s network, your claim might be denied. You can appeal if no local, in-network doctor could give you the care you needed.
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Experimental treatments
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A treatment might be considered too new or unproven, which might cause your insurance company to deny the claim. You can appeal by showing that accepted medical experts support this care.
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Canceled coverage
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If your insurance company stops your plan coverage for any reason, you can appeal that decision.
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Getting started with your appeal
A strong appeal relies on clear details and medical records. Gathering the right paperwork can help you present a full picture of your situation.
Start by finding your explanation of benefits (EOB), which outlines what services your doctor charged for, what your plan covered, and what you may owe. Your EOB will list the reason your claim was denied.
Next, you’ll want to talk to your doctor and gather some documents, like:
- Medical records. These office notes show your health history and explain why the treatment was chosen.
- A letter of support. This is a note from your doctor explaining why the denied service is the best option for your health. It can make a big difference in your appeal.
- Prior authorization details. If your doctor asked your insurance for approval before your visit, gather those forms and your insurance company’s response.
This will all be helpful when you write an appeal letter, which explains why you’re appealing.
Steps for writing a clear appeal letter
Your appeal letter is your chance to explain why a coverage decision should be changed. You don’t need to use fancy legal words or insurance jargon. Just be clear, honest, and factual.
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Step 1
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Make sure you include your basic details right at the top. You want to include your full name, your member ID number (which you can find on your insurance card), and your claim number.
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Step 2
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State exactly what you are appealing. Include the name of the medical service, the date you received it, and the name of the doctor who provided the care.
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Step 3
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Explain your reason for the appeal. Keep your sentences short and to the point. Focus entirely on the medical facts. For example, if a treatment wasn’t considered medically necessary, point directly to the letter from your doctor that explains how it was.
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Step 4
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End the letter by listing all the documents you have attached, like your medical records and your EOB. This can help your insurance company make sure they have all the right documents.
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What comes next
Once your letter is ready, send it to the address on your denial letter or your EOB. Some companies have an appeal form you’ll need to fill out as well. Be sure to watch the deadline. Many insurers require you to send your appeal within 180 days from the date you got the denial notice.
As you move through the appeal process, keep copies or use your phone to take a photo of everything you send. That includes your appeal letter, medical records, bills, and any notes from your doctor that support your need for care. It also helps to write down the date you mailed your appeal and any calls you made about your case.
Different insurance companies can have different appeals processes, and the timeline for an answer can vary based on how complex your appeal is. Keep an eye out for communication from your insurance company.
Take the confusion out of insurance
Get reliable answers to your insurance questions, such as how to get prior authorization and submitting a claim.
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How to submit a claim
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How to request prior review and authorization
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How to read your explanation of benefits
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