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. It is a records request, not an appeal.
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- 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 the denial rests on a medical judgment and you want to know whether the person who decided it has training in your condition. It works for job-based plans and for Marketplace or individual plans. The plan may answer with a name, a job title, or both; ask for everything the letter lists.
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]
13 November 2026
[Name and address of the plan's appeals department]
Re: Ask who reviewed your claim and their credentials Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
On [Date on the denial notice], [Name of the health plan] denied my claim [Claim or reference number] for [The care or drug that was denied]. The date of service was [Date of the care] and my member ID is [Member ID]. I am asking who made and reviewed that decision. This is a request for information. It is not my appeal.
Please tell me, in writing:
1. The name, job title, professional licence and area of medical specialty of each person who reviewed this claim, including any physician, nurse or other clinician. 2. The name, qualifications and specialty of each medical or vocational expert whose advice the plan obtained in connection with this denial, whether or not the plan relied on that advice. 3. Whether any outside company or review organization made or helped make the decision, and its name. 4. The date of each review.
The federal claims rule says a plan's procedures must provide for identifying the medical or vocational experts whose advice was obtained for the plan in connection with a denial, even if the advice was not relied on. When a denial rests on a medical judgment, the rule also requires the appeal to be decided in consultation with a health care professional who has appropriate training and experience in the relevant field, who was not consulted on the first decision, and who is not that person's subordinate. I am asking now so that I can prepare my appeal.
Please send the answer promptly, in time for me to use it in my appeal. I want proof of delivery, so please confirm in writing the date you received this request.
Enclosures: 1. Copy of the denial letter
Sincerely, [Your name]
Before you send it
Send it to the address the plan gives for appeals or member records. Look on your denial notice, your member card or the plan's website. If you cannot find one, call the member services number on your card, ask where written requests go, and write down the date, the person's name and any reference number. To prove it arrived, use certified mail with a return receipt, or fax it and keep the confirmation page, or send it through the plan's online portal and take a screenshot that shows the date. Keep a copy of the letter.
What to enclose
- Copy of the denial letter
What happens next
- You: send the letter and keep the proof of delivery.
- Plan: the claims rule requires the plan's procedures to provide for identifying experts, but it gives no number of days for this request. The letter asks for a reply in time for your appeal; note the date you sent it.
- You: do not wait for the answer if your deadline is close. For most job-based and individual plans you have at least 180 days after you receive the denial notice to appeal, and your plan may allow more. A grandfathered individual policy may give less. Check the date on your notice, which controls.
- You and your doctor: when the names arrive, ask your doctor whether the reviewer's specialty fits your condition. If it does not, say so in your appeal and ask for a reviewer with training and experience in the right field.