Imagine you need to get an MRI. You’ve had unexplained headaches with no discernable trigger, and your provider wants additional tests to rule out anything serious. So, you get a referral from your healthcare provider, make an appointment, and then wait until the scheduled day. Meanwhile, the radiologist’s office contacts your insurance to get the service approved. The day before your appointment, you get a call. Your insurance provider decided to deny the claim, which means you can’t have the scan. Or, worst-case scenario, you’ve already gotten it and your insurance denied the claim after the fact. Meaning, they won’t cover the cost.
Your insurance company may have had the right to deny your claim, sure. But you have the right to know why they denied it. Legally, your insurance company must let you know exactly why your claim was denied or why they terminated your insurance coverage (if they did). They’re also required to tell you that you can appeal their decision. And you should, by writing a health insurance appeal letter.
A letter of appeal to an insurance company is what you send to your insurance provider when they’ve denied a claim or ended your coverage. It’s your opportunity to disagree with whatever they’ve decided, and the company will then have to go through a review process to make sure everything was handled fairly and according to the law. You’re essentially asking them to reconsider their decision. This is something you can send, or your provider can appeal on a patient’s behalf as well.
“If your health plan denies coverage for a treatment, test, service, or surgery, it is important to note that you do have the option to challenge this, which is called an appeal,” says Ben Aiken, MD, a family physician at Lantern Health and the VP of Health at insurance administrator Decent . “If your appeal is successful, then you may receive coverage for the service by the insurance company.”
Here’s how to write an appeal letter to your insurance company.
There are two types of health insurance appeals — the first step is deciding which one is appropriate for your case.
Once you’re ready to appeal, write a letter including all the necessary information for an appropriate review of your claim. Noor Ali, MD, founder at Dr. Noor Healthcare Advisor , says that it also includes “strong supportive documents, [like] medical evidence, clinical notes, professional statements,” and more. The National Association of Insurance Commissioners suggests using the following as a good template for the letter .
Your Name
Your Address
Date
Address of the Health Plan’s Appeal Department
Re: Name of Insured
Plan ID #:
Claim #:
To Whom It May Concern:
I am writing to request a review of your denial of the claim for treatment or services provided by name of provider on date provided .
The reason for denial was listed as (reason listed for denial) , but I have reviewed my policy and believe treatment or service should be covered. Here is where you may provide more detailed information about the situation. Write short, factual statements. Do not include emotional wording.
If you are including documents, include a list of what you are sending here.
If you need additional information, I can be reached at telephone number and/or e-mail address . I look forward to receiving your response as soon as possible.
“When you respond, pay close attention to the reason for the denial, and make sure to address it in your appeal letter,” Dr. Aiken says. “Getting your provider involved can be an effective way to improve your chances of having a claim denial overturned.”
Your provider can provide a secondary letter as supplemental documentation to your letter—or they may be handling the appeal’s process entirely.
Just like everything else with health plans, Dr. Aiken says, yours likely has its own instructions on how to appeal a denial. Be sure you’ve checked exactly who to send it to and how (via regular mail or electronically) and what specific documentation your insurance company might require to be included.
Dr. Ali says the letter should typically be addressed to “the claims department or claims adjuster, or a specific department for appeals” at the insurance company. That information can be determined by looking at your plan information, finding the appeals page on your insurance company’s website, or calling the company to ask.
Insurance appeal letters need to be Health Insurance Portability and Accountability Act (HIPAA) compliant, which means you can generally only send them in ways that prevent fraud, Dr. Ali says. So, expect to physically mail your letter or fax it—but remember to first determine which method your insurance provider prefers.
Once you’ve sent your letter (and written down the date you sent it), it’s time to hurry up and wait. The letter will need to be received, logged, and processed, which typically takes about 30 days, Dr. Ali says. Some companies take longer, though. Follow up after 30 days, unless your insurance provider has given you different guidance.
If the response to your appeal leads to covered services, congratulations! You’re done. But if your appeal is rejected, then you have a few options.
“Generally, there are several levels to an appeal process,” Dr. Aiken says. “It means that if you are denied after the first appeal, you can appeal again. If denied after your first appeal, review the reasons for the second denial and include more documentation supporting your reasons for needing the care or treatment. After two or more denials, you can ask for an independent review, which means a clinician in the applicable specialty will be assigned to review the case.”
Ultimately, it comes down to exactly why your insurance rejected a service. According to data from the Centers for Medicare and Medicaid Services , those with Affordable Care Act plans in 2020 had denied claims for two main stated reasons: the service was excluded from their plan coverage, or preauthorization wasn’t provided for service. Dr. Aiken says that for excluded services, you’ll have an uphill battle trying to get the service approved. But for situations where there was a lack of prior authorization or no referral, you can get your healthcare provider involved and they can typically get the denial reversed.
Always remember: It’s your right to appeal a denial, and you should take the chance to do it.