Build your case
Write your appeal
Put the facts, the plan's error and your doctor's support into a short letter with the right enclosures.
Do this today
- Use the tool: Appeal letter builder Pick your denial reason and build an appeal letter with an enclosure list and a next-steps sheet.
- Read: How to assemble and send an appeal packet 5 minute read. Put your appeal letter, your doctor's letter, records and plan documents in order, then send the packet so you can prove the plan received it. Includes a check of what to enclose and what to keep.
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Put this step on My Plan
So you can come back to it, and keep your dates and calls in one place.
In brief
- Put the appeal letter first, then an enclosure list, then the papers in the order the letter mentions them. Send copies, never originals.
- Send to the appeals address on your denial notice by a method that proves delivery, and keep a full copy of what you sent.
- The plan's clock starts when you file under its procedures, even if you have more to add later. Send what you have by the deadline and add the rest with a cover note.
- Confirm receipt, write down the reference number, and mark the date the plan's answer is due.
Read the full guide: How to assemble and send an appeal packet
More guides, tools and letters
More guides, tools, letters 35
Guides
- How to assemble and send an appeal packet
Put your appeal letter, your doctor's letter, records and plan documents in order, then send the packet so you can prove the plan received it. Includes a check of what to enclose and what to keep.
- How to write an appeal letter that works
A plain structure for your appeal letter, from what you want to a request for a written decision. Includes what to put in each part, what to leave out, and links to letters for each denial reason.
- Writing your personal statement
How to write a short, honest account of what your condition and the denial have done to your health and daily life, to sit beside your doctor's letter in an appeal. Includes prompts and what to leave out.
Tools
- Tool
Appeal letter builder
Pick your denial reason and build an appeal letter with an enclosure list and a next-steps sheet.
- Tool
Appeal packet builder
Build a cover sheet and numbered enclosure list, with the steps to prove your appeal arrived.
- Tool
Evidence checklist builder
Get a tailored list of the documents that answer your denial reason, and who holds each one.
Letters and scripts
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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.
- Letter or script
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. Every clinical statement is a blank for the clinician to complete.
- Letter or script
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.
Programs and services
- Program or service
AppealArmor
A free web tool that reads a photo or text of your denial letter, shows you what it read, and emails an appeal letter and a Next Steps sheet with where to send it and your deadline. It also has a deadline calculator.
From AppealArmor
- Program or service
Arthritis Foundation Rx for Access insurance toolkit
A multi-page toolkit and a helpline for people with arthritis covering claims, common denial reasons, explanation of benefits, and appeals for private and government plans. Condition-specific: arthritis, including juvenile arthritis.
From Arthritis Foundation
- Program or service
Claimable
A paid service that builds an appeal for specific denied medicines and mails and faxes it for you. It lists about 85 medicines and does not cover other kinds of denial. Price is shown after you start.
From Claimable, Inc.
- Program or service
Counterforce Health
A free artificial intelligence (AI) appeal letter generator for individuals, plus a large blog of drug, insurer and state guides. The tool sits behind an intake form and an email account.
From Counterforce Health, Inc.
- Program or service
Crohn's & Colitis Foundation appeal letter library
Customizable appeal letters for Crohn's disease and ulcerative colitis treatments, tests and dose changes, including a request to use a biologic without first failing other drugs. Written for the doctor's office to edit.
From Crohn's & Colitis Foundation
- Program or service
Fight Health Insurance
A free tool that uses artificial intelligence (AI) to draft appeal letters from a photo or text of your denial letter. It also has a denial explainer, glossary and state help pages. Run by a company, not a nonprofit or law firm.
From Fight Health Insurance, Inc.
- Program or service
Health Appeal
A free service with an in-page deadline check and an appeal letter builder that works inside an artificial intelligence (AI) assistant or on its site. You sign and send the letter yourself.
From Health Appeal
- Program or service
Parity Registry appeal support for mental health and addiction care
A step-by-step guide to fighting a denial of mental health, eating disorder or addiction care under the federal parity law, with a complaint registry and a place to share your story. It does not file appeals for you.
From The Kennedy Forum
- Program or service
Patient Advocate Foundation appeals guide and sample letters
A free 10-page guide to appealing a health plan denial, with a fill-in-the-blank appeal letter, from a patient-advocacy charity. It is written for most private plans and does not give your own deadlines.
From Patient Advocate Foundation
- Program or service
Persius: denial support
An organization that says it helps people fight inappropriate coverage denials for free, using artificial intelligence (AI) with human review. It also does research on denials.
From Persius
- Program or service
Washington Insurance Commissioner: appealing a health insurance denial
Washington's insurance regulator explains how to appeal a denial, which plans it regulates, and where to find sample appeal letters by denial reason. Consumer advocates answer questions and take complaints.
From Washington State Office of the Insurance Commissioner
Questions to keep handy
- What exactly was denied, and under which part of the plan?
- What is my deadline, and what is it counted from?
- Where and how do I send my request, and how will I prove it arrived?
- Who decides, and can I ask for a faster decision?
Not what you need? Find a person who can help, or search the whole site.