How to Write an Appeal Letter to Your Health Insurance Provider

Picture this: You go to the doctor for the flu, to urgent care for a sprained wrist, or to the hospital for surgery. When you’re home recovering, you receive notification that your health insurance is denying coverage of the charges. Now what?

Under the Affordable Care Act (ACA), everyone has the right to appeal when their coverage is denied. You can appeal a health plan decision either internally (directly to the health plan itself) or externally (by going through an outside organization). 

If you decide to start with an internal appeal, you have 180 days from the time of the denial, and the request must be in writing. An appeal letter is a request for your health insurance to review the denial decision.

Here’s how to write a compelling appeal letter.

What to include in your appeal letter

To make it easy for your health insurance company to understand the issue, include these details at the beginning of the letter:

• Your name (as it is listed on the policy, including middle names/initials used on the policy)

• Policy number (found on your insurance card) 

• Policyholder’s name (if different from your name)

• Your contact information (mailing address, phone number, etc.)

• Date of denial, what was denied, and the stated reason for the denial (You can find this information on the explanation of benefits you received with the denial.)

• The healthcare professional’s name and contact information

State the reason for your appeal

In your letter, explain why you believe your insurance policy covers the treatment or service that has been denied. Mention the specific language in your policy that leads you to believe an error has been made.

For example, your healthcare professional may have removed a mole that they suspected might be cancerous. But the service was improperly coded as “cosmetic.” If your plan doesn’t cover cosmetic procedures, it may have denied coverage for the service. 

You should also request a statement from your healthcare professional explaining why you required the treatment or service. Include this statement when you send your appeal letter. The letter from your healthcare professional should also specify any errors that they made (if applicable). The previous example of improper coding would be considered an error made by the healthcare professional.

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Refer to any preauthorizations (if submitted), previous claims approved for the same treatments, X-rays, or other medical records that back up your case. 

Be concise, but don’t leave out any details related to the denied service.

A sample insurance appeal letter 

Here’s an example of what an appeal letter might look like.

[Policyholder’s name]
[Policy/member ID #]
[Address]
[City, state, ZIP code]
[Email address] 
[Phone number]
[Date]

[Health insurance company name] 
[Attn: Appeals department] 
[Address] 
[City, state, ZIP code] 

Re: Appeal for Denied Coverage of [specific procedure/treatment/medication] for [patient name] on [date of service]
Claim number: [your claim number] 

Dear [Insurance Company Representative/To Whom It May Concern],

I am writing to formally appeal the denial of coverage for [specific treatment/medication/procedure] on [date]. The claim was submitted on [date] under my policy with [your health insurance company]. It was not deemed medically necessary by your company. I believe that this decision should be reconsidered based on the enclosed documents and following information:  

Patient information

• Name: [Patient’s name]

• Date of birth: [Patient’s date of birth]

• Policy number: [Your policy number] 

Medical condition

• Diagnosis: [Your diagnosis]

• Medical services/treatment provided: [Services and treatment]

• Date of service: [Date of service]  

• Medical professional: [Medical professional’s name]

• Medical professional’s address: [Professional’s address]

Reason for appeal 

• Date of denial: [Date your service/treatment/medication was denied]

• What was denied: [Provide a brief description of the services/treatment/medication that was denied]

• Cited reason for the denial [Refer to the paperwork you received with the denial]

[Name of health insurance company] covers medically necessary services that [explain what type of services are considered medically necessary]. This information can be found in the [explain where you received the explanation of medically necessary services, include a quote from the source, and attach that source to the letter].  

My healthcare professional [name of medical professional] has recommended that this [service/medication/treatment] is medically necessary. [Attach letter of medical necessity from your healthcare professional]. 

[Describe your diagnosis and why the service, medication, or treatment would benefit you. Also, discuss alternative treatments that have been considered and tried without success. Explain why the recommended service/medication/treatment is the most effective option for your condition.]

Attachments: 

• Letter of medical necessity from [medical professional’s name]

• Relevant test results and medical records 

• Studies supporting the treatment 

• [Any additional supporting documentation]

Please review this appeal with the provided information and reconsider your coverage decision for [specific service/medication/treatment]. If you require any further information or clarification, please feel free to contact me or my medical professional.

Sincerely, 

[Your name]
[Your signature]

Download document

Edit and print sample letter

Personalize the letter to meet your specific needs. You should include all necessary information required by your insurance company. 

Send your appeal

Some insurance plans may allow you to send appeal letters by fax or email while others may require delivery via snail mail. If you submit the letter by fax, keep the confirmation of successful transmission until the entire appeal process has been completed. 

If you use snail mail, send the letter using certified mail and request a return receipt (proof of delivery). 

You must keep a copy of all items that you send to the insurance company (your letter, healthcare professionals’ statements, etc.), along with the proof of delivery. Store them in an organized way in a safe location so you can easily access them if needed. You should retain all this information until the entire appeal process has come to a close.

How long does it take for appeals to be reviewed?

Your insurance company should notify you within 10 days that your appeal has been received. If you do not receive confirmation (which will typically be in written form), contact your insurance company to make sure they received your appeal and it’s logged in their system.

Your insurance company must make a determination on the appeal within 30 days, and they must notify you of that decision in writing.

What should you do if you get an insurance denial letter? 

If your internal appeal is denied, the Affordable Care Act (ACA) allows you to request an independent external appeal. A third party conducts this review instead of the insurance company.

When an appeal is denied, the ACA requires health insurance companies to notify you of why your appeal was denied and of your right to an external appeal. They must also notify you of the availability of a Consumer Assistance Program, if your state has one. These programs help people who are having problems with their health insurance.

You can find more resources at HealthCare.gov.

References

Centers for Medicare & Medicaid Services. (2023). Consumer Assistance Program.