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.
- 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. When your coverage comes through your job and your claim or appeal was denied. Your employer may not be able to change a decision, but the office can tell you who runs the plan and where to send your appeal. Keep it short and factual. If you work for a government employer or a church, the Employee Retirement Income Security Act (ERISA) may not apply; ask human resources what law governs the plan.
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] 1. Say: "I am [Your name]. My health plan, [Name of the health plan], denied [The care or drug that was denied] on [Date on the denial notice]. I am appealing, and I would like help understanding the plan." 2. Ask: "Is our plan self-funded, meaning the company pays claims, or insured, meaning bought from an insurance company?" If they do not know, ask where the summary plan description says. 3. Ask: "Who is the plan administrator, and who decides claims? What is the address for appeals?" 4. Ask: "May I have the latest summary plan description and the plan documents? I will also ask in writing." 5. Ask: "Does the company have a contact at the insurer or claims company for problems? Can you ask them to look at my denial?" 6. Ask: "Is there any extra appeal step beyond the one in my denial letter?" 7. Ask: "Who will see the details of my claim in your office?" 8. Say: "I am filing my appeal by the deadline on my denial notice either way." 9. Write down: the person's name, the date, the time, what they promised and the date. Ask for a reference or an email confirming it. 10. Close: read your notes back and ask, "Is that right?" Say, "Thank you. I will send my request for the documents in writing today."
Before you call
Call or visit your employer's human resources or benefits office. Ask for the person who handles health plan questions. Write down who you spoke with, and ask them to confirm by email what they will do.
What happens next
- Send the written request for the plan documents the same day. If your plan is covered by the Employee Retirement Income Security Act (ERISA), it requires the plan administrator to furnish them on written request.
- File your appeal on time whatever human resources says. Check the date on your denial notice, which controls.
- If the answers are unclear, use the Department of Labor help request on this site.