Insurance appeal letter 2024 (guide + free sample)

An Insurance appeal letter is a short letter written by someone who has been denied an insurance claim.

This letter explains the situation and asks the insurance company to reconsider their decision.

Let me keep this more DRAMATIC so you can understand how things work

Here is the BAD news;

Your health insurance provider denied settling your emergency surgery treatment costs.

Whaaaaaaat?

Are you kidding (killing) me?

Before I even recovered?

Yeah!

Sure!

But that is not the end of your life, is it?

Hear some good news

Under the ‘Sec. 2719 of the Affordable Care Act (ACA) It is your RIGHT to appeal against insurance claims denials.

Yes, you can request your health insurance provider to reconsider their decision to deny covering your emergency surgery treatment costs.

Look!

You can challenge a decision made by your health insurer both INTERNALLY (directly with the provider) and EXTERNALLY (going through an outside organization usually your state’s insurance regulatory agency).

And you can easily do that through a piece of paper called an Insurance appeal letter.

To help you sail through the process, here I will guide you on;

• What is an Insurance appeal letter?
• Why do you need an Insurance appeal letter?
• Things to consider before writing your letter
• How to write a strong Insurance appeal letter
• Insurance appeal letter samples
  • Requesting an internal appeal
  • Requesting an external appeal
• What will make your appeal fail?
• What if your Insurance appeal letter does not work?
• How to increase the chance of winning your appeal
• etc.

Let’s get started

Related:

• Medical appeal letter (guide + free sample)
• Financial aid appeal letter templates
• Agent of record letter (guide, FAQs & samples)

What is an Insurance appeal letter?

An Insurance appeal letter is a brief statement of facts written by an insurance holder requesting reconsideration of his or her insurance claim denial.

As I said before, this letter is used to INITIATE both internal and external insurance appeals.

Now,

When it comes to an internal appeal, you have to write this letter DIRECTLY to the insurance company that denied your claim (within 180 days of the denial.)

But when it comes to an external appeal, you have to direct your letter to the state’s insurance regulatory agency.

Key Takeaway: An Insurance appeal letter is a letter that you write to your insurance company to challenge their decision to deny your claim.

Why do you need an Insurance appeal letter?

In short, you need an insurance appeal letter to exercise your legal right to challenge your insurer’s decision to deny your claim.

Of course;

If your health insurance company refuses to pay for your medical claim, you don’t have to accept their decision.

Especially when you find their justification to be incorrect.

The insurance company might have made a mistake, misunderstood your policy or treatment, or denied your claim unfairly or illegally.

Therefore it is your right to appeal their decision and defend your eligibility for coverage of your necessary medical care.

And writing an Insurance appeal letter to your insurance company to appeal the denial is one of your first steps in fighting a coverage denial.

Key Takeaway: You need to write an insurance appeal letter to challenge your insurer’s decision to deny your claim.

Things to consider before writing an Insurance appeal letter

Now you know the what and why.

Let me take you to the things that will determine the FATE of your Insurance appeal letter.

The following are the things to consider before writing an Insurance appeal letter.

Identify your type of insurance coverage

This is the first thing.

And it is very important.

Before writing your letter you have to identify the type of insurance coverage so that you can engage in the right appeal process.

To help you understand this point clearly;

There are THREE types of insurance plan

1. a group plan
2. government-sponsored plan
3. an individual plan

I strongly RECOMMEND you should first identify the type of your coverage because an appeal process available for a group plan may be different from a government-sponsored plan or individual plan.

Also, the health plan appeal process may be different from car insurance.

Here is a big one

Health insurance policies that were in place before the ACA was signed on March 23, 2010 (Grandfathered plans) have different appeal processes compared to new plans with effective dates after the ACA was signed unless they have made certain changes that cause them to lose their grandfathered status.

To be on the safe side, I advise you to contact your provider before writing your letter to learn what appeal process might be available to you based on your plan type.

Key Takeaway: The type of your coverage may determine the appeal process

Here is another thing;

Is your issue urgent?

Look!

If you are facing an URGENT situation, you may not be required to follow a normal appeal procedure (including writing a letter).

When I talk about urgent situations, I mean situations in which delaying treatment will endanger your life or overall health, impair your capacity to restore full function or subject you to severe and intolerable pain.

NB: A medical provider with knowledge of your medical condition is the one who certifies that your situation is urgent

In that case, your health plan will have to rule on your appeal through an expedited appeal procedure.

An expedited appeal procedure ALLOW you or your authorized representative to initiate your appeal verbally.

Where your health plan has to respond as quickly as possible, preferably within 24 hours, but no later than 72 hours.

They may give the response verbally, but it must be in writing within 72 hours of the decision.

Key Takeaway: Don’t bother to write an insurance appeal letter when you have an urgent medical condition

Check your bills

This is another important thing to do before writing your letter.

If your claim was refused, you have to rule out any billing mistakes first before taking a further step.

Checking your bill will give you a way forward

Whether you should appeal or dispute the bell;

Here is how you can do it,

Scrutinize all the documentation supplied to you by your health plan, start with an Explanation of Benefits (EOB) statement, etc., and confirm that:

• You (or a covered family member) visited a medical provider;
• The appropriate groups are represented (you, the provider, and the health plan);

If everything is correct check the medical bill sent by the medical provider to confirm;

• Charges
• Date of service
• If the Current medical codes and listed services you received are correct.

If any of these bill details are incorrect, you will need to dispute your medical bill with your medical provider instead of appealing to the insurer.

If you find that everything was correctly billed and you think your insurer should have covered the cost, then you can initiate the appeal process.

Key Takeaway: Verify the accuracy of billing information in all documents before drafting an insurance appeal letter. If there are any errors, you should dispute them with the medical provider. If everything is correct, you can start the appeal process.

Understand what is covered by your plan

You can never have a strong appeal reason (s) if you don’t understand what is covered and what is not covered by your plan.

Therefore;

Before writing your insurance appeal letter, peruse covered benefits in your most recent plan’s benefits handbook to understand what your health plan will and will not cover – this is included in the exclusions and limits section (for some plans, you may need to contact your health plan directly for this information).

Make sure you are satisfied yourself with

• Your health care benefits and any limits on the number of times you can use a specific benefit
• The deductible, if any, you must meet before the plan will start to pay for the medical care you received
• The benefits that require advance permission from your health plan, and how to get that approval
• etc.

Key Takeaway: Understanding what is covered in your plan, will help you write a strong appeal letter

Inform your medical provider’s your intention to appeal

Make sure you Inform your medical provider’s office that you want to appeal the denial and collaborate with them to resolve any outstanding bills.

Otherwise, you have three alternatives if a bill is due.

1. Delay paying it until the decision of your appeal is known.
2. Set up a payment plan and try to reduce the amount you owe (to avoid having the bill sent to collections), or
3. Pay the bill and get reimbursed by your health plan if your appeal is successful.

The choice is yours.

Key takeaway: You can resolve outstanding bills in a good way by informing your medical provider about your appeal process.

Gather important details (including documents)

Before writing your letter you MUST make sure you have all the necessary information and supporting documents to make it effective.

Make sure you have

• Your contact information (name, mailing address, phone number)
• Contact information for the person representing you, if applicable (such as an attorney,
• parent or guardian, provider, or a person who is acting as your attorney
• Name of the company or group providing the health plan
• Policy number and – if it applies – claim numbers
• If your plan is through your employer, the name and location of your employer
• Names of doctors or providers who provided care or who gave an opinion or recommendation

Documents you may need to gather to help you with your appeal include;

• Your most current benefits booklet
• Your insurance card
• All documents related to the situation you are appealing
• Any explanation of treatment or services from your medical provider’s office
• Any denials (also known by your health plan as adverse benefit determinations)
• Any research to support your opinion that the denial should be overturned

Key takeaway: Having supporting documents will help you present a strong appeal

How to write an effective Insurance appeal letter

An effective Insurance appeal letter is written in business letter format. Begin your letter with your address and contact information, followed by a date and the recipient’s address, salute the recipient, and begin your letter by indicating that you are writing to appeal against the claim denial and provide the grounds for appeal. Sign off with “Sincerely,” followed by your signature and name.

The following are some common reasons that you may include in your appeal letter as your grounds of appeal:

• That the treatment received was medically necessary
• That the insurer misunderstood your policy
• That the treatment received was recommended by a medical provider
• That the insurer’s justification is unlawful
• etc.

But, before you start writing, make sure you know

• The deadlines for filing an appeal (you may use our Legal deadline calculator, to calculate this)
• The department or person to whom you must address your letter.
• Specific information the insurer needs from you in order to reverse the original decision.

REMEMBER the primary goal of your Insurance appeal letter is to appeal against a claim denial.

So, in order to write an effective Insurance appeal letter, do the following;

• Include your name and contact information
• Include the date of the letter
• Include the name, position, and address of the recipient
• Include the Policy number
• Include the claim number,
• State the insurer’s justification for the denial
• Describe why the insurer’s justification is incorrect (reasons for appeal)
• Attach all necessary documentation including the Medical bills.
• Provide a clear statement of what you are hoping to achieve with the appeal.
• Be simple and straightforward
• Maintain a professional tone
• Be honest

after writing your letter

• Proofread
• print out two copies:
  • Send one copy via certified mail or any appropriate means
  • Save the second copy for your records and make a note of when you mailed it and when the insurance company received it.

Key takeaway: Writing a well-written, fact-based insurance appeal letter is vital for increasing your chances of success.

Insurance appeal letter sample (1st appeal)

The following is the sample Insurance appeal letter for lodging your first appeal-internal review based on medical necessity

Your Name
Your Address
City, State, Zip Code
phone
email

DATE

Recipient Name
Position
Department
Insurer Company Name
Street address
City, State Zip Code

RE: [Your Name]
Plan ID No: [068]
Claim No: [4687CD]

Dear Mr./Mrs./Ms. [Recipent’s last name]

I’m writing this letter to appeal against your decision to deny my payment for the ultrasound I obtained on March 14, 20… – Claim number 4687CD.

The reason given for the denial is that the service received was “not medically necessary.”

I believe that your decision is unjust because the ultrasound was recommended by Dr. Albert Song after conducting a professional examination of my health situation.

In addition to including a letter from Dr. Albert Song, who thought it was medically necessary, I asked Dr. Abbas Thomas, which is a contracted provider, how much the ultrasound would cost me out of pocket. His office stated that I would only be responsible for $23.

Based on the above reasons I hereby request you reconsider your decision and allow my claim.

Please let me know if you require any additional information from me in order to review my claim.

Enclosed with this letter

• A letter from my doctor describing why he thought the ultrasound was necessary (see a sample medical necessity letter)
• A recent article explaining how standard ultrasounds are essential for situations like mine (high enzyme count in the liver)

I look forward to resolving this outstanding bill as soon as possible.

Sincerely

[Your Signature]
[Your name]

Insurance appeal letter sample (2nd appeal)

The following is the sample Insurance appeal letter for lodging your second appeal-external review

Your Name
Your Address
City, State, Zip Code
phone
email

DATE

To whom it may concern

This is to notify you that I am aggrieved with the internal review decision of [name of insurer] delivered on [date] and I’m writting this letter to request an external review by your organization as an independent review organization due to the following reasons

• [reason 1]
• [reason 2]
• etc.

Based on the above reasons I hereby request you reverse the decision of [inusrer] and allow my claim.

Enclosed with this letter

• [insurer] decision
• a letter from my doctor describing why he thought the ultrasound was necessary
• A recent article explaining how standard ultrasounds are essential for situations like mine (high enzyme count in the liver)

[Your Signature]
[Your name]

What will make your appeal fail?

The following are the things that will make your appeal fail.

And you should avoid them at all costs.

• To submit your appeal past the deadline
• Poor formatting and hard-to-read appeal letter
• Poor factual organization
• Too many unnecessary details
• Incomplete appeal letter.
• Lack of important attachments-a letter from your medical provider etc.
• Rather than facts, they are highly emotional and include feelings of frustration, anguish, or anger.
• etc.

Apart from that, you may lose your appeal when;

• your carrier believes your request is outside its contractual responsibility
• your carrier believes THE ISSUE IS BETWEEN you and your employer for example when an employer informs the group health plan provider that a worker is no longer eligible for coverage as of a certain date, and the health plan denies all claims submitted for that person after that effective date

Key takeaway: To avoid failing in your appeal, make sure to submit your appeal on time, organize your appeal letter well, avoid unnecessary details, include important attachments, present factual information rather than emotional outbursts, and ensure that the issue is within your carrier’s contractual responsibility.

What if your Insurance appeal letter does not work?

The following is what you can do if your Insurance appeal letter does not work depending on different circumstances.

If it is your first appeal (internal review) consider appealing to the next level (external review)

In case you have exhausted all levels but still have no success here is what you can do

1. If the insurer stated that the issue is between you and your employer you may consider filing a complaint with the United States Department of Labor – Employee Benefits Security Administration
2. You may ask your health plan for an exception
3. Find other means to pay the bill anyway (recommended when external review fails)

How to increase the chance of winning your appeal

The following is how you can increase the chance of winning your appeal

• Provide easy-to-prove facts
• Be straightforward and include only the necessary information
• Submit your appeal on time
• Be specific on the outcome you expect
• Demonstrate that you or your medical practitioner followed the terms of your health plan.
• Attach all necessary documents.

Resource: How to appeal a health care insurance decision