65 templates
Letters and phone scripts
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Ask for documents and records
Start here. Ask for the file before you write the appeal. 8
- Ask for a denial in writing
A written request for a proper denial notice when the plan has only told you by phone that it will not approve or pay.
For: Job-basedMarketplace
- Ask for an itemized bill
A written request to a provider for an itemized statement of every charge, code, payment and adjustment on your account…
Any coverage
- Ask for the clinical criteria used
A written request for the internal rule, guideline or clinical explanation the plan used to deny your care, so your appeal can answer it point by point.
For: Job-basedMarketplace
- Ask for the parity comparison for a mental health denial
A written request for the plan's mental health parity comparison and the medical necessity criteria behind a mental health or substance use denial…
For: Job-basedMarketplace
- Ask for your claim file
A written request for everything the plan used or created when it decided your claim, sent before you appeal.
For: Job-basedMarketplace
- Ask for your medical records
A written request to your doctor, hospital or clinic for a copy of your own medical record under the federal health privacy rule, for use in your appeal.
Any coverage
- Ask for your plan documents
A written request to your employer plan's administrator for the summary plan description and the documents that set the plan's rules, so you can check the denial against them.
For: Job-based
- Ask who reviewed your claim and their credentials
A written request to learn who decided your claim and what medical experts the plan consulted, with their roles, specialties and licences.
For: Job-basedMarketplace
Appeal letters you sign
One for each kind of denial. 19
- Appeal: approved, then denied
Asks your plan to pay a claim for care it approved in advance, and to explain what changed and which plan provision lets it deny payment after approval.
For: Job-basedMarketplace
- Appeal: coding error and reprocessing
Asks your plan to reprocess a claim that was denied because of a billing or coding mistake, after your provider has corrected and resubmitted it.
For: Job-basedMarketplace
- Appeal: emergency care denied
Asks your plan to cover an emergency visit using the prudent layperson standard, judged on your symptoms at the time rather than the final diagnosis.
For: Job-basedMarketplace
- Appeal: ending of ongoing treatment
Asks your plan to keep covering treatment it already approved while you appeal a decision to reduce or end it, and to decide before the benefit stops.
For: Job-basedMarketplace
- Appeal: equipment or supplies
Asks your plan to cover medical equipment or supplies it denied, using your plan's own wording, your prescriber's order and how the equipment is used in your daily life.
For: Job-basedMarketplace
- Appeal: experimental or investigational
Asks your plan to reverse an experimental or investigational denial, to explain its clinical reasoning for your diagnosis, and to answer the evidence your doctor relies on.
For: Job-basedMarketplace
- Appeal: filed too late
Asks your plan to accept a claim it called late, by showing when it was first sent, quoting the plan's own filing rule, and asking it to apply any exception it contains.
For: Job-basedMarketplace
- Appeal: formulary exception
Asks your plan to cover a drug that is not on its drug list, or to lift a quantity limit, using your prescriber's reasons why the covered alternatives do not fit.
For: Job-basedMarketplace
- Appeal: level of care
Asks your plan to approve the level or setting of care your clinician recommended, such as a hospital stay or residential program, instead of a lower one.
For: Job-basedMarketplace
- Appeal: mental health or substance use care with a parity argument
Asks your plan to reverse a mental health or substance use denial and to produce its criteria and comparative analysis under the federal parity law.
For: Job-basedMarketplace
- Appeal: not a covered benefit
Asks your plan to name the exact provision it relied on and to cover care that falls within a benefit your plan document describes.
For: Job-basedMarketplace
- Appeal: not medically necessary
Asks your plan to reverse a medical necessity denial, using the plan's own standard and your records, and to have a clinician in the right field review it.
For: Job-basedMarketplace
- Appeal: out of network because no in-network option exists
Asks your plan to cover out-of-network care at the in-network level because no in-network provider could give the care in time, or at all.
For: Job-basedMarketplace
- Appeal: out-of-network allowed amount too low
Asks your plan to explain how it set the allowed amount for out-of-network care, to reprocess the claim if the method was wrong, and to pay the difference.
For: Job-basedMarketplace
- Appeal: prior authorization denied
Asks your plan to reverse a refusal of approval before care, to say what standard it applied, and to decide with a clinician in the right field.
For: Job-basedMarketplace
- Appeal: step therapy exception
Asks your plan to excuse you from trying other drugs first, using the drugs you have already tried and your prescriber's reasons, and to send its step therapy rules.
For: Job-basedMarketplace
- Ask your plan to reprocess a claim under the No Surprises Act
Ask your plan to reprocess a claim with the No Surprises Act protections, so you pay only in-network cost sharing that counts toward your in-network limits…
For: Job-basedMarketplace
- Request an expedited appeal
Asks your plan to decide an appeal as an urgent claim, within 72 hours, because waiting could seriously harm your health, and to contact your doctor.
For: Job-basedMarketplace
- Second-level internal appeal
Asks for a second review inside your plan after a first appeal was denied, answering the first decision's reasons and adding what is new.
For: Job-based
Letters your clinician signs
Give these to your doctor's office to adapt. 6
- Certification of urgency (for your clinician)
A short letter in a physician's voice stating that the standard time frame could seriously harm the patient, so the plan must treat the claim or appeal as urgent and decide within 72 hours.
For: Job-basedMarketplace
- Letter of medical necessity (for your clinician to adapt)
A letter in your clinician's voice that explains the diagnosis, what has been tried, why the denied care is medically necessary for you, and what is likely to happen without it.
Any coverage
- Off-label or experimental use letter (for your clinician)
A letter in your clinician's voice that responds to an experimental, investigational or off-label denial with the clinical reasons and the evidence for this patient.
For: Job-basedMarketplace
- Out-of-network necessity letter (for your clinician)
A letter in your clinician's voice explaining why in-network care cannot meet the patient's needs, so the plan should cover an out-of-network provider.
For: Job-basedMarketplace
- Peer-to-peer call brief (for your clinician)
A one-page set of notes in your clinician's voice for a call with the plan's reviewing doctor: the three points to make, the questions to ask and what to record.
Any coverage
- Step therapy exception letter (for your clinician)
A letter in your clinician's voice asking the plan to skip a required first-try drug because it has failed, is unsafe or is otherwise not right for you.
For: Job-basedMarketplace
Go beyond the plan
External review, regulators, Medicare, Medicaid and your employer. 11
- Appeal my Medicaid plan's cut and keep my services going
Ask your Medicaid health plan to appeal a cut or ending of a service you already get, and to keep the service going while it decides.
For: Medicaid
- Ask your employer to review the denial
A polite written request to your employer's benefits office to look into a denial, name the plan administrator and send the plan documents.
For: Job-based
- Complaint to your state insurance department
Tell the state agency that regulates insurance companies what your insurer did, what you already did, and what you ask the agency to do.
For: Job-basedMarketplace
- Medicaid fair hearing request
Ask your state for a fair hearing when Medicaid denied, reduced or stopped a service.
For: Medicaid
- Medicare Advantage reconsideration request
Ask your Medicare Advantage plan to review its denial again.
For: Medicare
- Medicare drug plan exception request
Ask your Medicare drug plan to cover a drug that is not on its list, or to charge a lower cost-sharing tier.
For: Medicare
- Medicare redetermination request
Ask the Medicare contractor to review again a decision on your Original Medicare claim.
For: Medicare
- No Surprises Act complaint
Tell the federal government that you were billed more than the No Surprises Act allows, using the No Surprises Help Desk or the online complaint form.
For: Job-basedMarketplaceMilitary, federal
- Request expedited external review
Ask for a fast independent review, decided within 72 hours, when waiting could seriously harm your health.
For: Job-basedMarketplace
- Request external review
Ask for an independent review of your plan's final denial by reviewers outside the plan.
For: Job-basedMarketplace
- Request help from the Department of Labor
Ask the federal agency that oversees employer health plans to look at how your plan handled your claim and tell you your next steps.
For: Job-based
Bills, debt and credit
Protect yourself while you appeal. 6
- Ask a collector to validate a debt
Ask a collection company in writing to prove what it says you owe, and to pause collection while you appeal and check the bill.
Any coverage
- Ask the provider to hold the bill
Ask a provider in writing to pause collection, interest and late fees on a bill while your insurance appeal is decided.
Any coverage
- Dispute a medical debt on your credit report
Ask a credit reporting company to investigate a medical account on your report that is wrong, unsettled or still under insurance appeal.
Any coverage
- Hospital financial assistance cover letter
A cover letter to send with your hospital's financial assistance application, asking for a hold on the bill and a written decision.
Any coverage
- Offer to settle a medical bill
Offer a single payment to settle a medical bill in full, and ask for the agreement in writing before you pay.
Any coverage
- Tell the provider the No Surprises Act may apply to your bill
Write to the provider's billing office to say the federal No Surprises Act may apply, ask them to bill only your in-network share, hold the account while your plan reprocesses the claim…
For: Job-basedMarketplace
Phone scripts
What to say, what to ask for, and what to write down. 11
- Phone script: appeal to your Medicaid plan and keep services going
What to say when you phone your Medicaid health plan to appeal a cut or ending of services and keep them going during the appeal, what to ask for, what to do if told the provider must ask…
For: Medicaid
- Phone script: ask for a peer-to-peer review
What to say to your doctor's office and your plan to ask for a call between your doctor and the plan's reviewing physician.
Any coverage
- Phone script: ask for reprocessing
What to say to your plan and to the provider's billing office to get a paperwork denial corrected and the claim processed again.
Any coverage
- Phone script: ask Medicare for a fast appeal when care is ending
What to say when you phone the Medicare quality reviewer to ask for a fast appeal because a hospital stay, nursing facility, rehabilitation or home health care is ending…
For: Medicare
- Phone script: call your regulator
What to ask when you call the agency that oversees your plan, so you learn which agency is right and how to file a complaint.
Any coverage
- Phone script: chase an appeal that has gone silent
What to say and ask when you have filed an appeal and heard nothing, including the federal decision deadlines for job-based and individual plans.
For: Job-basedMarketplace
- Phone script: first call after a denial
What to say and ask on your first call to your plan after a denial, and what to write down before you hang up.
Any coverage
- Phone script: first call to the billing office about a surprise bill
What to say on your first call to a provider's billing office about a bill that may be a surprise bill: what to ask for, what to write down, how to ask for a hold in writing…
For: Job-basedMarketplace
- Phone script: pharmacy rejection
What to ask at the pharmacy counter and then your plan when a prescription is rejected, so you learn why and what to send.
Any coverage
- Phone script: talk to human resources
What to ask your employer's benefits or human resources office to learn who runs your plan and to get the plan documents.
For: Job-based
- Phone script: three-way call with your provider
How to bring your doctor's office onto a call with your plan so that both sides hear the same facts and agree on what happens next.
Any coverage
Other
4
- Cover sheet for an appeal packet
A one-page cover sheet that lists everything in your appeal packet and how you sent it, so nothing is missed and you can prove what arrived.
Any coverage
- Name someone to act for you
A plain written statement naming a family member, friend or advocate to speak and write to your health plan for you about a claim or appeal.
Any coverage
- Note to your doctor's office
A short, courteous note to your doctor's office that says exactly what you need for your appeal, whether that is a letter, records, a call to the plan or a billing check, and by what date.
Any coverage
- Tell the plan it missed its deadline
A letter that tells your plan it did not decide your claim or appeal in time, quotes what the federal rule says follows…
For: Job-basedMarketplace
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