Appealing to your insurance company can certainly seem intimidating. But it doesn’t have to be if you stay organized! It’s important to keep your medical information organized so that you can build a compelling counterargument addressing the original denial and provide supporting documentation. The letter can be addressed from you, or an advocate or medical provider written on your behalf.
Elements of the letter:
- Patient name, policy number, and policy holder name
- Accurate contact information for patient and policy holder
- Date of denial letter, specifics on what was denied, and cited reason for denial
- Doctor or medical provider’s name and contact information
Be sure to include your detailed case as to why the plan should cover the claim:
- State why you need the prescribed medical service and why you believe your insurance policy covers the treatment or service. Cite plan language where possible.
- Ask your medical provider to prepare a letter of medical necessity explaining prior treatments, the reason the treatment in question is being ordered, and that it is necessary for your situation.
- Provide and reference published journal articles or treatment guidelines from an industry recognized group or institution, demonstrating outcome benefits and treatment success.
- Anything else that supports your request, including copies of pre-authorizations if submitted, second opinions, etc.
Sending Your Submission:
- Track submission. If submitted by fax, keep the confirmation of successful transmission. If submitted by mail, send the letter by certified mail with a request of a return receipt.
- Keep a copy of the letter, all submitted materials, the delivery or submission receipt and your record of all correspondence prior to and following the submitting of your appeal in a safe and organized place.
- You should receive an official notice within 7-10 days that your appeal has been received. If you do not receive confirmation, contact your insurance company to make sure your appeal has been received and shows in their system.
For appeal letter examples, check out our Sample Appeal Letter for Denied Claim or Sample Appeal Letter for Denied Prior-Authorization.
