Internal appeal packet

Work out your deadline from the date on the noticeA group health plan must give you at least 180 days after you receive the denial notice to appeal, your plan may allow more, and the date on your notice controls.Ask for your claim file, free of chargeThe plan must give you copies of the documents, records and other information relevant to your claim, including anything it relied on or considered.Ask for the plan's clinical criteria and the reviewer's identityThe plan must provide for identifying the medical experts it consulted on the denial, and must give you its internal rule or clinical reasoning on request.Decide whether the situation is urgentIf waiting could seriously jeopardize your life or health, ask for a fast appeal instead, which the plan must decide within 72 hours.

A copy of the denial letter and the Explanation of BenefitsThe reviewer needs to see exactly which decision you are appealing and which claim it covers.Your appeal letterSay which decision you are appealing, what you want the plan to do, and why the plan's reason is wrong, using the claim numbers from the denial.A letter from your doctorYour doctor can explain why the treatment is medically necessary for you, and the plan must consult a health care professional with the right training and experience when the denial rests on a medical judgment.Medical records and test results that answer the plan's stated reasonThe reviewer must consider all the comments, documents and records you submit, including material the plan did not have the first time.A form naming your authorized representative, if someone files for youA plan must let an authorized representative act for you, and a health care professional who knows your condition may act in an urgent case.Your notes of calls with dates, times, names and titlesPhone notes show the reviewer what the plan told you and when.

Send it by a method that gives proof of deliveryCertified mail, a fax confirmation or a dated portal receipt shows when the plan received your appeal, and the plan's clock starts when you file under its reasonable procedures.Keep a full copy of everything you sendYou will need the same packet later if the plan upholds its denial and you ask for external review.Do not pay a feeA plan cannot charge a fee to file a claim or an appeal.

Write down the date the plan's decision is dueThe plan must decide an urgent appeal within 72 hours, a pre-service appeal within 30 days and a post-service appeal within 60 days, or half of the 30 or 60 days at each level if the plan has two levels. An urgent appeal is still 72 hours at each level.Respond to any new evidence the plan sends youBefore a final denial, a plan that is not grandfathered must give you any new evidence or reasoning it used, free of charge and early enough for you to respond.Note it if the plan misses a deadline or breaks its own rulesIf a non-grandfathered plan fails to strictly follow the internal appeal rules, you may go straight to external review or to court.If the plan upholds the denial, check the final denial letterIt will tell you the external review process and form, and you have at least four months after receiving it to ask.

Internal appeal packet

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