Key points
- Put the appeal letter first, then an enclosure list, then the papers in the order the letter mentions them. Send copies, never originals.
- Send to the appeals address on your denial notice by a method that proves delivery, and keep a full copy of what you sent.
- The plan's clock starts when you file under its procedures, even if you have more to add later. Send what you have by the deadline and add the rest with a cover note.
- Confirm receipt, write down the reference number, and mark the date the plan's answer is due.
An appeal packet is your appeal letter and everything that backs it, sent together. Put it in order, send copies, send it to the address on your denial notice in a way that proves delivery, and keep a full copy. File by your deadline even if one document is still missing; you can add it later.
What this means
The reviewer sees only what is in the file. The packet is how you put your case in it. A short, ordered packet is easier to read than a stack.
The plan must consider all the comments, documents and records you submit, including material the first reviewer did not see. The plan’s time to decide starts when you file under its procedures, whether or not you have sent everything. Both facts point the same way: file on time with what you have, and add to it.
What to do
- Check the notice for how to appeal (your step). Find the appeals address, any form, and the deadline. Some plans have a form. The Crohn’s & Colitis Foundation’s checklist lists “the insurer’s appeal form” among enclosures when there is one.
- Gather the papers. Use the internal appeal packet checklist or the appeal packet builder. The usual contents:
- your appeal letter, signed and dated;
- a copy of the denial notice and your Explanation of Benefits (EOB);
- your doctor’s letter of medical necessity;
- the medical records that support it;
- the plan’s criteria and the claim file pages you rely on;
- guidelines or studies your doctor cites;
- your personal statement;
- the plan’s appeal form, if it has one; and
- an authorized representative form, if someone else is acting for you.
- Put them in order. Letter first, then a numbered enclosure list, then the papers in that order. Number the pages if you can, so your letter can say “see enclosure 3, page 2”.
- Make copies. Send copies, never originals. Keep a complete duplicate of the packet.
- Choose how to send it. Use the method that gives you proof:
- certified mail with a return receipt;
- a fax, with the confirmation page kept; or
- the plan’s portal, with a saved confirmation or screenshot that shows the date. The Department of Labor’s booklet also advises certified mail with a return receipt and keeping copies. The Patient Advocate Foundation’s sample letter tips are the same.
- Send it early. Do not leave it to the last day. Look up how the plan counts the date it received your appeal. See how deadlines are counted.
- Confirm it arrived. Call a few days later. Ask for the date received and a reference number, and write both down. See how to talk to your insurer on the phone.
- Mark the answer date. Count from the day the plan received it. The plan must decide within 72 hours for an urgent appeal, 30 days if the care has not happened yet, and 60 days if you are asking it to pay for care you have had. If your plan has two appeal levels, each level has half of the 30 or 60 days, and an urgent appeal is still 72 hours at each level. Check the date on your notice, which controls.
- Log it. Record the date, the method, who it was addressed to, and any tracking number in your call log or the appeal tracker.
If you need to add something later
Send the new document with a short cover note: your name, claim number, the date of your appeal and what is attached. Use the same proof of delivery. The plan must consider it. Send it as early as you can, and ask the plan to confirm it is in the file.
What the plan may say, and what to say back
“We did not receive your appeal.” Send your proof of delivery, such as the return receipt or fax confirmation, and ask the plan to log the original filing date.
“Your appeal is incomplete.” The plan’s clock starts when you file under its procedures, even if you have not sent everything. Ask what is missing, in writing, and send it.
“Your appeal is late.” Compare the date you received the notice with the time limit in the notice and the plan document. Your plan may allow more than 180 days. Ask the plan to name the document that sets its limit.
The rule
The clock for a plan to decide an appeal starts when the appeal is filed under the plan’s reasonable procedures, whether or not all the information needed to decide it came with the filing. See section 2560.503-1(i)(4) of Title 29 of the Code of Federal Regulations (CFR): 29 CFR 2560.503-1.
Watch for
- Urgent appeals. For an urgent appeal you may ask orally or in writing, and information moves by telephone, fax or a similarly fast method. See how to get an expedited appeal.
- Medicare. For an Original Medicare redetermination, the request counts as filed on the day the contractor receives it, so mail early. See Medicare.
- Different forms. Medicaid, military and other public coverage use their own forms and addresses. Use the ones on your notice.
- Sending to the wrong place. If a letter goes to a general address, call and ask where appeals go, and resend.
What next
- How to file an internal appeal: what the plan does with your packet.
- When the insurer misses its deadline or goes silent: what to do if the answer date passes.
- How to keep a call log and paper trail: record every step.