Key takeaways:
Under the Affordable Care Act (ACA), most health plan enrollees have the right to ask their insurer to review a coverage denial. This is known as making an appeal.
An appeal letter should describe the decision you want reviewed, explain why you disagree, and state your desired outcome. Include facts and documents to support your case.
You can request an independent external review if your internal appeal is denied.
Picture this: You see your primary care provider for the flu, visit urgent care for a sprained wrist, or have surgery, and while recovering, you receive notice in the mail that your health insurance is denying coverage for the charges. Now, what?
Under the Affordable Care Act (ACA), most health plan members can ask their insurer to review a coverage denial. This is called making an appeal. You can appeal a coverage decision either internally (directly through your insurer) or externally (through an outside organization).
If you decide to proceed with an internal appeal, you have 180 days after you receive the denial notice to challenge the decision. Your health plan may require you to complete a form or submit an appeal letter. You can also ask for an external appeal at the same time if it’s an urgent matter.
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Include the claim information, prior authorization number, if applicable, and the reason for the denial in your appeal letter. You can also attach medical records and a supporting letter from your healthcare professional.
Below, we discuss these and other tips for writing a compelling appeal letter.
How do you write an appeal letter?
An appeal letter should start by stating the decision you want reviewed. Explain why you disagree with the denial. Clearly state the outcome you want. (Most likely, this will be having the decision reversed and your service, treatment, or medication covered.) And include facts and documents that support your request.
Before writing the appeal letter, review the denial notice and your plan’s appeal rules. Check the deadline for submitting the letter and confirm if there are any required forms or documents you must include.
What to include in your appeal letter
To make it easy for your health insurance company to process your appeal, include these details at the beginning of your letter:
Your full name (as it is listed on the policy)
Policyholder’s name (if different from your name)
Policy number (as listed on your insurance card)
Your contact information (such as your mailing address, phone number, and email)
Date of denial, what was denied, and the stated reason for the denial, which you can find on the explanation of benefits you received about your care
Name of the healthcare professional who provided your care and their contact information
Tips for writing an effective appeal letter
Applying these suggestions can help you write a compelling appeal letter:
State your request at the beginning. Say that you are appealing a coverage denial. Name the treatment, service, or medication that was denied for coverage.
Address the reason for the denial. Explain why you disagree with the health insurance company’s decision.
Refer to the language in your policy. Point out the part of your policy that refers to covering the care, which may be included in your summary of benefits and coverage. Use the exact language in your policy that leads you to believe an error was made.
Explain how the care meets your plan’s medical-necessity criteria. There are guidelines that your insurer uses to decide if care is medically necessary and should be covered. Explain why the treatment, service, or medication meets this criteria and include documentation that supports your claim. The healthcare professional who provided your care can help you with this.
Attach supporting documents. If applicable, include relevant prior authorizations, medical records, test results, or similar claims that were covered in the past.
State the action you want your insurer to take. Ask your health insurance company to reverse the denial and cover the treatment, service, or medication in clear, straightforward language.
Be factual, brief, and respectful. Focus on the facts that relate to the denial, and include important, relevant details. Don’t provide false or exaggerated information, and avoid insults or threats. Use a professional tone, and proofread the letter before you send it.
Example of an appeal letter
Here’s an example of what an appeal letter might look like. To use this as a template, replace the information in brackets with details related to your case.
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[Policyholder’s name]
[Policy/member ID number]
[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 treatment/service/medication] for [patient name]
Date of service: [date, if applicable]
Claim number: [the claim number]
Dear [Appeals Reviewer],
I am writing to appeal the denial of coverage for [treatment/service/medication]. The denial notice states that [reason given in the notice].
I believe [treatment/service/medication] should be covered. My health insurance policy states that [language from the policy that refers to covering the care]. This care meets those requirements because [explanation of how it meets the policy’s coverage rules or medical-necessity criteria, or why the denial was based on incorrect information].
My healthcare professional, [healthcare professional’s name and credentials, such as M.D.], recommended this care to treat [medical condition].
I have included [list of attached documents, such as medical records, test results, or prior authorizations] to support my appeal request. I have also included a letter from [healthcare professional’s name] that explains why this care is needed.
Please review this appeal request with the provided information and reconsider your coverage decision for [treatment/service/medication]. If you require any further information or clarification, please feel free to contact me or my medical professional.
Sincerely,
[Printed name]
[Signature]
Personalize the letter to meet your specific needs. You should include all necessary information required by your insurance company.
Send your appeal
Most insurance plans allow you to send appeal letters by fax, mail, or email. If you submit the letter by fax, keep the confirmation of successful transmission. If you send the letter by mail, use certified mail and request a return receipt as proof of delivery.
You should keep a copy of all the items that you send to your insurance company, including your appeal letter and any statements from healthcare professionals, along with the proof of delivery. Store the copies in an organized way and in a safe location, so you can easily access them if needed. You should retain all this information until the entire appeal process has concluded.
How long does it take for appeals to be reviewed?
Insurers must respond to appeal requests within a set time period. How long they have depends on the type of appeal:
Care needed urgently: If waiting for a decision could seriously harm your health, you may qualify for an expedited appeal. In this case, your health insurance company must notify you of the decision within 72 hours.
Care you have not yet received: If you’re appealing a coverage denial for upcoming medical care, your insurer has 30 days to make a determination and respond.
Care you’ve already received: If the appeal is related to care you’ve already received, your insurer must respond within 60 days.
Check your denial notice for the review timeline that applies to your appeal. Your insurer must issue the final decision in writing.
Your insurer may confirm receiving your appeal request by mail, email, or a message in your member portal inbox. You can always call to confirm receipt if you don’t see a confirmation. Write down the date, time, case number, and name of the representative you speak with.
What should you do if you get an appeal denial letter?
If your internal appeal is denied, you may be able to request an independent external review under ACA rules. In this case, an outside reviewer, rather than your insurance company, will decide whether the denial should stand.
The internal appeal denial letter must explain how to request an external review. It must also include information about your state or territory consumer assistance program, if one exists. Consumer assistance programs offer help with health insurance issues.
You can find more resources through HealthCare.gov.
Frequently asked questions
Do not include false or unrelated information in an appeal letter. Avoid threats or insults. Focus on the denial, the facts that support your appeal request, and the action you want your health insurance company to take.
An artificial intelligence (AI) tool can help you organize your information and create a first draft of an appeal letter. But you must carefully review the letter and verify that all the information is accurate before submitting it to your health plan. The AI tool may include inaccurate details or make other mistakes.
Don’t share certain protected health information (PHI), such as your name, Social Security number, phone number, or email address, with an AI tool. You can add those details later, outside of the AI system.
Begin an appeal letter by stating that you are challenging a coverage decision. State the service or item that was denied for coverage and include the claim number, if available. For example, you might start an appeal letter by saying: “I am writing to appeal the denial of coverage for [treatment, service, or medication].”
Do not include false or unrelated information in an appeal letter. Avoid threats or insults. Focus on the denial, the facts that support your appeal request, and the action you want your health insurance company to take.
An artificial intelligence (AI) tool can help you organize your information and create a first draft of an appeal letter. But you must carefully review the letter and verify that all the information is accurate before submitting it to your health plan. The AI tool may include inaccurate details or make other mistakes.
Don’t share certain protected health information (PHI), such as your name, Social Security number, phone number, or email address, with an AI tool. You can add those details later, outside of the AI system.
Begin an appeal letter by stating that you are challenging a coverage decision. State the service or item that was denied for coverage and include the claim number, if available. For example, you might start an appeal letter by saying: “I am writing to appeal the denial of coverage for [treatment, service, or medication].”
The bottom line
If your health plan denies coverage for a treatment, service, or medication, you may be able to file an appeal. Your plan may require you to complete an appeal form or submit an appeal letter. The letter should explain what was denied, why you believe the care should be covered, and the information you have to support your case.
Before submitting an appeal, review the denial notice, your summary of benefits and coverage, and your health plan’s appeal rules. Check the deadline for making the appeal and make sure you know what documents are required.
If your internal appeal is denied, you may be able to ask an independent organization to externally review the decision.
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References
Centers for Medicare & Medicaid Services. (2024). Appealing health plan decisions.
Centers for Medicare & Medicaid Services. (2024). Consumer assistance program.
Healthcare.gov. (n.d.). Appealing a health plan decision: Internal appeals.
Healthcare.gov. (n.d.). How can I get consumer help if I have insurance?
Isola, S., et al. (2023). Protected health information. StatPearls.
Washington State Office of the Insurance Commissioner. (n.d.). Common reasons for a denial and examples of appeal letters.
