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.
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- A template, not legal advice
When to use this, and what it is not
When to use this. When you have just received a denial and want to learn the exact reason, the rule behind it and your deadline. Call the member services number on the back of your insurance card. This call does not replace a written appeal.
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 script
Your script
Date of this call: [Date of the call] Before you call, have your denial letter, your card and a pen. 1. Say: "My name is [Your name]. I am calling about claim [Claim or reference number] for [Doctor, hospital or pharmacy], date of service [Date of the care]. My member identification (ID) number is [Member ID]." 2. Ask: "May I have your name and a call reference number?" Write both down. 3. Ask: "May this call be recorded?" Write down their answer. 4. Ask: "What is the exact reason this claim was denied? Is it a paperwork or coding problem, or a coverage or medical decision?" 5. Ask: "Which plan rule or medical policy did you use? Please send me a copy." 6. Ask: "I would like my claim file, free of charge. Where do I send that request in writing?" 7. Ask: "Can this claim be corrected and reprocessed without an appeal? If so, who must send what?" 8. Ask: "What is my deadline to appeal, and what date is it counted from? Where do I send the appeal? Is there a fast appeal if my health is at risk?" 9. Write down: the person's name and ID number, the date, the time, the reference number, what they promised and the date they promised it. 10. Close: "Let me repeat what we agreed." Read your notes back and ask, "Is that right?" Say, "Thank you. I will follow up in writing." Do not rely on the call alone. Put your appeal in writing unless you were told in writing that a phone request is enough.
Before you call
Call the member services number on the back of your insurance card, or the number on your denial letter. Ask for a call reference number at the start and again at the end of the call.
What happens next
- Write up the call the same day: name, ID, date, time, reference number, what was promised and by when.
- Ask for your claim file in writing. Job-based and individual plans must give you free access to the documents relevant to your claim, and Medicaid managed care plans must give you the case file free of charge.
- Find your deadline on the denial notice. For most job-based and individual plans a first appeal must be allowed for at least 180 days after you receive the notice. Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different deadlines, often shorter, and they are on your notice. Check the date on your notice, which controls.