Why Appeal A Health Claims Denial… and How to Do It Right

Why should I appeal?

By appealing a claims denial, you are challenging the insurance company’s decision to deny benefits. Even if you think your appeal will not be approved, you should still appeal:

  1. To get treatment records considered.
  2. To fill the claim file with support for the patient’s treatment.
  3. To “exhaust” appeals. This means that you have done all the appeals required under the policy before filing a lawsuit.

How do I appeal?

Appeals can be done in three ways:

  1. Expedited – You will need to show medical need for expedited basis. Providers have these “peer to peer calls” by having a telephone conversation with a doctor who works for the insurer or claims administrator.
  2. Written – Send a written appeal letter. Send it by certified mail so you can confirm it was received.
  3. Telephone call – You can just call and say “I appeal this denial” (this is not the best option but it will suffice in a pinch).

A written appeal is your best way to get a comprehensive review of your claim. Even if there was a peer to peer appeal by telephone, fax or email treatment records so they are in the claim file. Cases have been won, and lost, based on what was sent in on appeal.

When should I appeal?

Generally first level appeals are due within 180 days from receipt of the denial letter or explanation of benefits (EOB) that shows that the insurance company denied the claim. Second level appeals can be due in a shorter time period, often 60 days. Review your policy for the exact time frame that applies to your appeal. If you can’t get your policy, or are otherwise uncertain about deadlines, call your insurance company and ask them to confirm the deadline for you in writing.

What should I say in the appeal letter?

You want to be organized and plan what you are going to write. If you are not the patient/insured, you want to state who you are, your relation to the patient (i.e. “I am her physician/therapist/mother”) and your contact information. Be sure to date the letter.

Give a brief biography. It can be as short as a few sentences that explain diagnosis, treatment history, and need for treatment.

Summarize any prior correspondence and quote directly from the denial letter. Explain why the denial letter got it wrong.

Conclude with a specific request. Example: “Please overturn the denial and promptly pay the benefits for the treatment.”


What should I enclose with the appeal letter?

The enclosures are your evidence. First and foremost, you should enclose medical records that support the requested treatment. You could also enclose letters of support from physicians and notes documenting the prior telephone calls that precipitated the appeal.

Anything else?

You also have a right to ask for information. Ask for the name of the medical reviewers who reviewed your claim for the insurance company. Ask for the credentials of the medical reviewers. Under ERISA (the federal law governing employer provided plans), you are entitled to know the identification of all “medical professionals” who reviewed your appeal. The insurance company must “provide for the identification of medical or vocational experts whose advice was obtained on behalf of the plan in connection with a claimant’s adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination” 29 C.F.R. 2560.503-1 (h)(3)(iv).

For more information on writing an appeal letter: http://www.kantorlaw.net/Practice-Areas/Eating-Disorders/How-to-Write-an-Appeal-Letter-Like-an-Attorney.aspx

More good tips on appeals: http://www.latimes.com/business/lazarus/la-fi-lazarus-winning-insurance-appeals-20170117-story.html


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