How to Write an Insurance Appeal Letter
Knowing how to write an insurance appeal letter that will get positive results from your insurance company can save you money. With claim denials by insurance companies trying to cut costs increasing in frequency, writing insurance appeal letters is essential to getting the most out of your health insurance plan.
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Things You'll Need
- Computer
- Word Processing Program
- Printer
- Notice of Claim Denial from Your Insurance Company
- Envelope
- Stamp
Instructions
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Examine the notice of claim denial from your insurance company to locate the reason for the claim denial. This is often listed in tiny print at the bottom of the page, and may say something vague like "service not covered under member's plan."
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Find the customer service phone number on the the notice, and call your insurance company. Be prepared to spend some time on hold, but don't hang up! When you do talk to an actual person, be sure to ask for and make a note of his or her name.
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Ask for a detailed explanation of the claim denial, and tell the representative that you'd like to appeal the decision. Make a note of what they say and thank the representative for his or her help.
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If you've resolved the issue over the phone, request that the representative send you something in writing confirming that they will pay the claim. In the more likely event that they tell you that they need to file a written request for appeal, you'll need to continue with the steps below.
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Go to your doctor's office and request that they write a letter of medical necessity and fax it to your insurance company along with any related medical records. Finally, make sure that you get a copy of the doctor's letter to include with your own letter to the insurance company.
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Gather the claim notice, the notes from your phone conversation with the insurance company, and the letter from your doctor. Include the date at the top of your letter, then your name, address, and policy number.
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In the body of your letter, mention the date and type of service for which the insurance company refused to pay, and the telephone conversation you had with the insurance company's representative. Note that your doctor will also be sending them a letter, and that you are including a copy.
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Ask that the company reconsider their decision, and let them know you will be following up with them if you haven't heard from them in 30 days. Make and keep a copy of your letter and the supporting documentation for your records.
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Mail the letter and documentation to the insurance company, and consider sending an additional copy by certified mail, return receipt requested. This ensures that you have proof later of sending your letter, in case you do need to pursue some sort of legal action at a later date.
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If you have not heard from your insurance company within 30 days, follow up by phone. If this first appeal is rejected, don't be afraid to ask for an additional appeal. If you still get no results, contact your state's insurance commissioner (see resources below).
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Tips & Warnings
Make sure your letter is typed rather than handwritten, as a typed letter looks more professional and is much easier to read.
Keep all paperwork related to the denied claim together in a folder that you can easily grab to talk on the phone with your insurance company, or consult when you receive a reply.
Make sure that you know the provisions of your insurance plan, including what services require pre-authorization and what doctors and hospitals are approved by your insurance company.
Don't threaten the insurance company in your letter, and don't be abusive when you call. The representative you speak to is likely not responsible for the denial of your claim, and he or she will be much more helpful if you are courteous.
Resources
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