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.
- Private: nothing leaves this tab
- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this when your plan denied or underpaid care because the provider is out of network, and you could not get the same care from an in-network provider. Keep a log of every in-network provider you tried.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
14 November 2026
[Name and address of the plan's appeals department]
Re: Appeal: out of network because no in-network option exists Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am appealing the decision dated [Date on the denial notice] on claim [Claim or reference number], which denied or reduced payment for [The care or drug that was denied] from [Doctor, hospital or pharmacy] on [Date of the care] because the provider is out of network. The plan's reason was: [The reason the plan gave] I ask you to reverse that decision and cover this care at the in-network benefit level under [Name of the health plan], member ID [Member ID].
My plan documents say this about out-of-network care: [What your plan documents say about out-of-network care] I ask the plan to decide whether this care can effectively be provided in its network.
I needed the care [How soon you needed the care]. I was not able to get it from an in-network provider. Here is what I tried: [Which in-network providers you tried and what happened] I chose this provider because: [Why this provider can give the care] My treating doctor is [Your treating doctor's name and specialty].
If the plan says an in-network provider can give this care, I ask it to name that provider and to show that the provider treats my condition and could have seen me when my doctor said I needed care. If the plan cannot do that, I ask it to approve this provider.
Under the federal claims and appeals rules, including Title 29 of the Code of Federal Regulations (CFR), sections 2560.503-1 and 2590.715-2719 (for individual coverage, 45 CFR 147.136), I am entitled to a full and fair review. I ask that someone who was not involved in the first decision, and who is not that person's subordinate, decide this appeal and give no deference to the first decision. If the decision rests on a medical judgment, I also ask that you consult a health care professional with training and experience in the field of my condition who was not consulted on the first decision. Please consider every record and comment I send, including anything that was not before the first reviewer.
Please send me your decision in writing within the time the rules allow. If you uphold the denial, I will ask for external review by an independent organization and may complain to the agency that regulates my plan.
Enclosures: 1. Copy of the denial letter or Explanation of Benefits 2. My log of in-network providers I contacted 3. Letter from my treating doctor explaining why this provider is needed 4. The page of my plan document about out-of-network care
Sincerely, [Your name]
Before you send it
Send it to the appeals address printed on your denial notice, by a method that proves delivery, such as certified mail with a return receipt or the plan's online portal with a saved confirmation page. Keep a complete copy of the letter and everything you enclose, and write down the date and the method you used.
What to enclose
- Copy of the denial letter or Explanation of Benefits
- My log of in-network providers I contacted
- Letter from my treating doctor explaining why this provider is needed
- The page of my plan document about out-of-network care
What happens next
- Your plan must decide within 30 days after it receives your appeal if the care has not happened yet, or within 60 days if you have already had it. If your plan has two appeal levels, each level gets half that time. Check the date on your notice, which controls.
- Write down every in-network provider you call from now on, with the date and the answer. Then ask the plan in writing for its own list of in-network providers for this service in your area.
- If the plan says no again, ask for external review. Federal rules treat a denial as reviewable when your plan covers out-of-network care if the service cannot effectively be provided in network. For most job-based and individual plans you have at least four months after you receive the final denial to ask. Check the date on your notice, which controls.
- You can also complain to the agency that oversees your plan. A complaint does not stop your appeal deadline, so file the appeal first.
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".
The rule behind this
- 29 CFR 2590.715-2719, internal claims and appeals and external review
- 45 CFR 147.136, internal claims and appeals and external review
- 29 CFR 2560.503-1, claims procedure
- 45 CFR 149.420, out-of-network providers at in-network facilities
- 42 U.S.C. 300gg-115, provider directories
- 42 U.S.C. 300gg-113, continuity of care
Sources
- 29 CFR 2590.715-2719, internal claims and appeals and external review
- 29 CFR 2560.503-1, claims procedure
- 45 CFR 147.136, internal claims and appeals and external review
- 45 CFR 149.420, out-of-network providers at in-network facilities
- 42 U.S.C. 300gg-115, provider directories
- 42 U.S.C. 300gg-113, continuity of care
Denial reasons this answers
- Denial reason
Out of network
The plan says your provider or facility is not in its network. Federal law protects you in emergencies and in several hospital situations, so check which situation you are in before you pay.