Insurance appeal letter 2023 (guide + free sample)

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This post covers everything you need to know about an insurance appeal letter.

The bad news

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

Whaaaaaaat?

Are you kidding (killing) me?

Before I even recovered?

Relax

That is not the end of your life.

Here is some good news

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

YEeeeeS!

How do I go about that?

Here is how it works

A decision made by a health insurer may be challenged both internally (directly with the provider) and externally (going through an outside organization usually your state’s insurance regulatory agency).

If you choose to begin with an internal appeal, your request for this type of appeal must be made in writing within 180 days of the denial.

Here is where an Insurance appeal letter becomes necessary.

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)

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.

In case of internal appeal, an Insurance appeal letter is written directly to the insurer appealing the denial.

When the insurer does not change its decision as a result of the internal appeal, an Insurance appeal letter may also be written to request external review (second appeal) by the state’s insurance regulatory agency.

Why do you need an Insurance appeal letter?

You do not have to accept your health insurance company’s decision if they refuse to pay for a medical claim.

Insurance companies refuse coverage for a number of reasons, and in your situation, their justification may be incorrect.

They might have erred, they might have misunderstood your policy or the nature of your treatment, or they might have refused your claim in bad faith or for unlawful justifications.

You have the right to appeal the decision and defend your eligibility for coverage of the necessary medical care.

Writing a letter to your insurance company to appeal the denial is one of your first steps in fighting a coverage denial.

Things to consider before writing an Insurance appeal letter

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

These things will determine the fate of your letter, so be careful.

Identify your type of insurance coverage

Identifying the right type of insurance coverage will help you engage in the right appeal process.

Generally, there are three types of insurance plan

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

Sometimes an appeal process available for a group plan is different from the government-sponsored plan or individual plan.

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

The biggest of all is that a health insurance policy that was in place before the ACA was signed on March 23, 2010 (Grandfathered plans) unless they’ve made certain changes that cause them to lose their grandfathered status they have different appeal processes compared to New plans with effective dates after the ACA was signed.

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

Is your issue urgent?

Generally, you may not be required to go with a normal appeal procedure (including writing a letter) if you are facing an urgent situation.

If your condition is urgent, your health plan will rule on your appeal more quickly than if it is not.

This is known as an expedited appeal.

You or your authorized representative can file your expedited appeal verbally with your health plan.

Your health plan must 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.

Urgent indicates that a medical provider believes that 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

Check your bills

If your claim was refused, rule out any billing mistakes first.

Scrutinize the documentation supplied to you by your health plan, start with an Explanation of Benefits (EOB) statement, 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 details are not correct then you will need to dispute your medical bill to your medical provider instead of appealing to the insurer.

If you find that everything was appropriately billed and you believe your insurer should have covered the cost, then you may proceed with the appeal process.

Understand what is covered by your plan

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.

Inform your medical provider’s your intention to appeal

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

Generally, 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.

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 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

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.

A well-written, fact-based appeal letter is vital to your chances of success.

But, before you start writing, be sure you know

  • The deadlines for filing an appeal.
  • 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.

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. Albert Song, 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 a $23 co-pay.

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

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 things will make your appeal fail.

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

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

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Isack Kimaro
Isack Kimaro

Holder of Bachelor of Laws (LL.B) and Post Graduate Diploma in Legal Practice. I am dedicated to providing valuable and easy-to-understand legal information for individuals at all levels of understanding. Whether you are a layperson looking to increase your knowledge, a law student striving to excel in your studies, or a practicing lawyer wanting to expand your expertise, I am here to help. I'm not creating content, I'm creating awareness to empower you to take control of your legal understanding and achieve your goals.