HEALTH PLAN INTERNAL APPEAL

SEND VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED

Date: [__/__/____]

CLAIMANT INFORMATION

Patient Name: [________________________________]

Date of Birth: [__/__/____]

Member ID Number: [________________________________]

Group Number: [________________________________]

Social Security Number (last 4 digits): XXX-XX-[____]

Address: [________________________________]

City, State, ZIP: [________________________________]

Telephone: [________________________________]

Email: [________________________________]

APPELLANT INFORMATION (If Different from Patient)

Appellant Name: [________________________________]

Relationship to Patient: [________________________________]

Address: [________________________________]

Telephone: [________________________________]

Authorized Representative?
☐ Yes – Signed authorization attached
☐ No – Appellant is the patient

SEND TO:

[Insurance Company/Plan Name]
Appeals Department
[Address]
[City, State, ZIP]

Phone: [________________________________]

Fax: [________________________________]

RE: FORMAL INTERNAL APPEAL OF ADVERSE BENEFIT DETERMINATION

Claim Number: [________________________________]

Date of Denial: [__/__/____]

Date(s) of Service: [__/__/____] to [__/__/____]

Type of Service/Treatment Denied:
☐ Hospital/Inpatient Services
☐ Outpatient Procedure
☐ Prescription Drug
☐ Diagnostic Testing (MRI, CT, Lab Work)
☐ Durable Medical Equipment
☐ Mental Health/Substance Abuse Treatment
☐ Physical/Occupational Therapy
☐ Specialist Consultation
☐ Pre-authorization Request
☐ Other: [________________________________]

Amount in Dispute: $[________________]

Dear Appeals Committee:

I am writing to formally appeal the adverse benefit determination issued on [__/__/____], which denied coverage for [description of service/treatment]. This appeal is submitted pursuant to the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1133, and the Affordable Care Act's internal claims and appeals requirements, 42 U.S.C. § 300gg-19 and 45 C.F.R. § 147.136.

This appeal is timely filed within 180 days of my receipt of the denial letter.

STATEMENT OF DENIAL

According to the Explanation of Benefits (EOB) or denial letter dated [__/__/____], coverage was denied for the following stated reason(s):

☐ Service is not medically necessary
☐ Service is experimental or investigational
☐ Service is not covered under the plan
☐ Prior authorization was not obtained
☐ Provider is out-of-network
☐ Service is subject to a plan exclusion
☐ Maximum benefit has been reached
☐ Service requires step therapy first
☐ Incorrect coding/billing issue
☐ Other: [________________________________]

Specific Denial Language:
[________________________________]
[________________________________]
[________________________________]

TYPE OF APPEAL

☐ Standard Internal Appeal (Decision within 30-60 days)

☐ Expedited/Urgent Care Appeal (Decision within 72 hours)

This appeal is urgent because:
☐ Waiting for a standard decision could seriously jeopardize the patient's life, health, or ability to regain maximum function
☐ The patient is currently undergoing treatment that will be discontinued without approval
☐ Other urgent circumstances: [________________________________]

GROUNDS FOR APPEAL

I respectfully request that you reverse the adverse benefit determination for the following reasons:

1. Medical Necessity

The denied service/treatment is medically necessary for the following reasons:

[________________________________]
[________________________________]
[________________________________]
[________________________________]

Supporting Medical Evidence:
- [List diagnoses, ICD-10 codes]
- [Describe patient's condition and treatment history]
- [Explain why this treatment is appropriate]
- [Discuss consequences of denial]

2. Compliance with Plan Terms

The denied service/treatment is covered under the terms of the Plan because:

[________________________________]
[________________________________]
[________________________________]

Specific Plan Provisions:
[Reference specific plan language that supports coverage]

3. Clinical Guidelines and Standards of Care

The recommended treatment is consistent with accepted clinical guidelines and standards of care, including:

☐ [Medical Society/Organization] Guidelines
☐ FDA-approved indications
☐ Peer-reviewed literature
☐ Clinical trial evidence
☐ Other: [________________________________]

4. Errors in the Denial

The denial was based on the following errors:

☐ The Plan applied the wrong standard or criteria
☐ The Plan failed to consider all relevant medical evidence
☐ The Plan reviewer was not qualified to evaluate this type of treatment
☐ The Plan used outdated clinical guidelines
☐ Coding/billing errors occurred
☐ Other: [________________________________]

TREATING PHYSICIAN'S STATEMENT

Physician Name: [________________________________]

Specialty: [________________________________]

Contact Information: [________________________________]

Statement:

I, Dr. [Physician Name], am the treating physician for [Patient Name]. In my professional medical opinion, the recommended treatment/service is medically necessary because:

[________________________________]
[________________________________]
[________________________________]

Without this treatment, the patient faces the following risks:

[________________________________]
[________________________________]

I recommend that the Plan's denial be reversed and coverage be approved.

Physician Signature: ___________________________________

Date: [__/__/____]

NPI Number: [________________________________]

ADDITIONAL EVIDENCE AND DOCUMENTATION

The following additional evidence is submitted in support of this appeal:

☐ Letter of Medical Necessity from treating physician
☐ Updated medical records from [Provider Name] dated [__/__/____]
☐ Laboratory/diagnostic test results
☐ Pathology report
☐ Imaging studies (MRI, CT, X-ray)
☐ Peer-reviewed medical literature supporting treatment
☐ Clinical guidelines from [Organization Name]
☐ FDA approval documentation
☐ Second opinion from specialist
☐ Previous authorization or approval history
☐ Other: [________________________________]

Attached Documents:

1. [________________________________]
2. [________________________________]
3. [________________________________]
4. [________________________________]
5. [________________________________]

REQUEST FOR CLAIM FILE AND RELEVANT DOCUMENTS

Pursuant to 29 C.F.R. § 2560.503-1(h)(2)(iii), I request copies of all documents, records, and information relevant to this claim, including but not limited to:

☐ All medical records reviewed
☐ All criteria or guidelines used to deny the claim
☐ The qualifications of the medical reviewer who evaluated the claim
☐ Any internal rules or protocols applied
☐ All communications regarding this claim

Please provide these documents within 30 days as required by law.

REQUIREMENTS FOR FULL AND FAIR REVIEW

I am entitled to the following rights under ERISA and the ACA:

1. Independent Review: This appeal must be reviewed by individuals who were not involved in the initial denial and who are not subordinates of those individuals.

2. Medical Expert Consultation: If this denial was based on medical judgment, the appeal must be reviewed by a health care professional with appropriate training and experience who was not consulted in the initial denial.

3. No Deference: The appeal reviewer must not give deference to the initial denial.

4. Consideration of All Evidence: The reviewer must consider all evidence and information submitted, regardless of whether it was submitted during the initial claim.

5. New Evidence Disclosure: If any new evidence or rationale is developed during the appeal, it must be provided to me sufficiently in advance of the decision for me to respond.

FOR URGENT/EXPEDITED APPEALS

If this is an urgent appeal, I request:

☐ A decision within 72 hours (or as soon as possible given the medical urgency)
☐ Notification by telephone or electronic means
☐ Continuation of coverage during the appeal if treatment is ongoing

Contact for Urgent Response:

Phone: [________________________________]

Email: [________________________________]

NOTICE OF INTENT TO PURSUE EXTERNAL REVIEW

Please be advised that if this internal appeal is denied, I intend to pursue all available remedies, including:

1. External Review: Under the ACA, I have the right to an independent external review by an accredited Independent Review Organization (IRO).

2. State Insurance Commissioner: I may file a complaint with the state insurance commissioner.

3. Federal Court Action: I reserve all rights under ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B), to file a civil action in federal court.

CONTACT INFORMATION

Please direct all correspondence regarding this appeal to:

Name: [________________________________]

Address: [________________________________]

City, State, ZIP: [________________________________]

Phone: [________________________________]

Email: [________________________________]

CERTIFICATION

I certify that the information provided in this appeal is true and accurate to the best of my knowledge.

Signature: ___________________________________

Printed Name: [________________________________]

Date: [__/__/____]

ENCLOSURES

☐ Copy of Denial Letter/EOB dated [__/__/____]
☐ Authorization for Release of Medical Information (if representative)
☐ Letter of Medical Necessity
☐ Medical Records
☐ [Additional enclosures as listed above]

IMPORTANT DEADLINES AND INFORMATION

Internal Appeal Deadlines

• You have 180 days from receipt of the denial to file this internal appeal
• The Plan must decide standard appeals within 30 days (pre-service) or 60 days (post-service)
• Urgent appeals must be decided within 72 hours

External Review Rights

If the internal appeal is denied, you have the right to an external review:
- Request Deadline: 4 months from receipt of final internal appeal denial
- Standard External Review Decision: Within 45 days
- Expedited External Review Decision: Within 72 hours

Deemed Exhaustion

If the Plan fails to strictly adhere to all applicable requirements, you are deemed to have exhausted the internal appeals process and may immediately seek external review or file suit in federal court.

STATE-SPECIFIC INFORMATION

[Note: Some states have additional appeal rights and shorter deadlines. Check your state's requirements.]

State Insurance Department Contact:

[________________________________]

Phone: [________________________________]

Website: [________________________________]

SOURCES AND REFERENCES

• 29 U.S.C. § 1133 - ERISA Claims Procedure
• 29 C.F.R. § 2560.503-1 - Claims Procedure Regulations
• 42 U.S.C. § 300gg-19 - ACA Internal Claims and Appeals
• 45 C.F.R. § 147.136 - Internal Claims and Appeals and External Review
• DOL Technical Release 2010-01

This template is provided for educational and informational purposes. Seek qualified legal counsel for specific advice regarding your health plan appeal.