Preparing a Written Appeal Letter for Insurance Company
If you find it necessary to file a written appeal of a decision made by an insurance company about your medical care, you will want to include information falling into four basic categories:
- Medical Records
- Your Appeal Letter
- A Letter From Your Doctor
- Supporting Documents (research, practice guidelines, etc.)
This is a list of things to research and focus on in preparing to write your appeal letter:
- Focus on the stated reason for the denial. Some common reasons include: unsupported therapy, experimental therapy or an uncovered service.
- Applicable plan benefits and rules that support your assertions.
- Review standards of care, practice guidelines and guidance from professional societies.
- Peer-reviewed research studies on use of this treatment or medication for people with your condition.
- Try to understand the insurance company's position so you can argue against it.
Here are some tips for things to include when writing your appeal letter:
- Information that identifies you and the decision you are appealing: policy number, group number, claim number, etc.
- State the reason they gave for their denial decision.
- Provide a brief history of your condition and why this treatment is necessary.
- Specify why you believe they made the wrong decision.
- Reference any research you found that demonstrates the treatment is not experimental or unsupported and include it in the packet with your other appeal documents.
- Address whether the treatment or medication is FDA approved for your disease or any purpose.
- If you believe they based their decision on incorrect information, make sure to address this and provide the correct information.
- Be specific: Ask them to reconsider their denial decision and do so in a timely manner.
Often examples can be very helpful when you are unfamiliar with the ins and outs of a process. You can download a sample in PDF form at this link: Sample Appeal Letter.
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