What your denial letter should contain

The specific reason or reasons for the denialThe notice must be written in a way you can understand and name the reason, not just a code.The plan provisions the denial relies onThe notice must point to the specific parts of your plan that the plan applied.Enough detail to identify the claimA plan that is not grandfathered must include the date of service, the provider and the claim amount where there is one.The denial code and what it meansA plan that is not grandfathered must include the denial code and its meaning.The standard the plan used to deny the claimA plan that is not grandfathered must describe the standard that it applied, such as a coverage rule or medical necessity test.

The internal rule, guideline or protocol, or an offer of a free copyIf the plan used one, the notice must either set it out or say a copy is available free on request.For a medical necessity or experimental denial, the clinical explanationThe notice must explain the scientific or clinical judgment as it applies to your medical circumstances, or say you can get that explanation free on request.What more the plan needs from you, and whyIf the plan says your claim is missing something, the notice must say what and why it matters.A statement that you can ask for the diagnosis and treatment codesA plan that is not grandfathered must tell you these codes and their meanings are available on request.

How to start an internal appeal and the time limitThe notice must describe the plan's review procedures and time limits, and the plan must give you at least 180 days after you receive the denial, so check the date on your notice, which controls.How to start an external reviewA plan that is not grandfathered must explain how to ask for independent review outside the plan.Contact details for a state consumer assistance program or ombudsmanA plan that is not grandfathered must include these so you can get free help.For an urgent claim, a description of the fast review processA denial of urgent care may be given by phone first, and a written notice describing the expedited review must follow within 3 days.For an Employee Retirement Income Security Act (ERISA) employer plan, your right to sueThe notice must say you can bring a civil action under ERISA section 502(a) after a denial on review.

A discussion of the decision, if this is the final denial after your appealA final internal denial from a plan that is not grandfathered must include a discussion of the decision, not only a code.A statement that you can have copies of all relevant documents freeA denial on appeal must say you may receive, free on request, copies of all documents relevant to your claim.Help in your language, if many people in your county read the same non-English languageIf 10 percent or more of the people in your county are literate only in the same non-English language, the plan must give oral help and the notice in that language on request.For a mental health or substance use denial, an offer of the reasonThe reason for the denial of mental health or substance use disorder benefits must be made available to you on request.

What your denial letter should contain

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