Internal Health Insurance Appeal

Instructions for Use

This template is for filing an internal appeal of an adverse benefit determination (claim denial) with your health insurance company. Under the Affordable Care Act and ERISA, you have the right to appeal any denial of coverage or payment.

Key Deadlines:
- File appeal within 180 days of denial (or as specified in plan)
- Insurer must decide within 30 days (pre-service) or 60 days (post-service)
- Urgent/concurrent care: Decision within 72 hours (or 24 hours if expedited)

Important: You must exhaust internal appeals before requesting external review (in most cases).

Internal Appeal Letter

[Date]

VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED
[Also submit via insurance portal/fax for expedited processing]

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

INTERNAL APPEAL - URGENT REVIEW REQUESTED
(Remove "URGENT" if not applicable)

Re: Appeal of Adverse Benefit Determination

Dear Appeals Committee:

I am writing to formally appeal the adverse benefit determination dated [DATE] denying coverage for [BRIEF DESCRIPTION OF SERVICE/TREATMENT]. This appeal is submitted pursuant to my rights under the Affordable Care Act (45 CFR 147.136), ERISA (29 CFR 2560.503-1), and the terms of my health insurance policy.

I request that this appeal receive a full and fair review by qualified personnel who were not involved in the original denial decision.

Section 1: Summary of Denial

Original Claim Information

Reason for Denial (as stated in denial letter)

☐ Not medically necessary
☐ Experimental/investigational
☐ Not a covered benefit
☐ Out-of-network provider
☐ Prior authorization not obtained
☐ Service not pre-certified
☐ Cosmetic procedure
☐ Pre-existing condition exclusion
☐ Exceeds benefit limits
☐ Coding error
☐ Untimely filing
☐ Duplicate claim
☐ Coordination of benefits issue
☐ Other: ______________________________________________

Denial Reason Code (if provided): ______________________________________________

Quote exact denial language from letter:

_______________________________________________________________________________

_______________________________________________________________________________

Section 2: Type of Appeal

Appeal Category (Check one)

☐ Pre-Service Appeal - Requesting coverage for planned/future service
- Scheduled Date of Service: ______________________________________________

☐ Post-Service Appeal - Requesting payment for service already received
- Date(s) of Service: ______________________________________________

☐ Concurrent Care Appeal - Ongoing treatment being reduced/terminated
- Current Treatment End Date: ______________________________________________
- Requested Continuation: ______________________________________________

Urgency Level

☐ URGENT/EXPEDITED REVIEW REQUESTED

I request expedited review because:

☐ My life or health is in serious jeopardy
☐ Standard timeframe would jeopardize my ability to regain maximum function
☐ I am experiencing severe pain that cannot be adequately managed
☐ A physician has certified urgency (attached)

Expedited requests require decision within 72 hours (24 hours for urgent pre-service)

☐ Standard Review - 30-60 day timeframe acceptable

Section 3: Grounds for Appeal

Why the Denial Should Be Overturned (Check all that apply)

Medical Necessity Arguments:

☐ The service IS medically necessary based on:
☐ My treating physician's clinical judgment
☐ Peer-reviewed medical literature
☐ Clinical practice guidelines
☐ My individual medical history and condition
☐ Failure of conservative treatments

☐ The denial did not consider all relevant medical information

☐ The reviewer was not appropriately qualified (wrong specialty)

☐ The plan's medical necessity criteria are being misapplied

Coverage Arguments:

☐ The service IS a covered benefit under my plan
- Plan document reference: ______________________________________________

☐ The denial misinterprets plan language

☐ The service falls under an exception to the stated exclusion

☐ The denial violates Mental Health Parity requirements

☐ The denial violates the No Surprises Act protections

Procedural Arguments:

☐ Prior authorization WAS obtained (Reference #: __________________)

☐ The provider IS in-network

☐ The claim WAS filed timely

☐ Required documentation WAS submitted

☐ The denial notice was deficient under 45 CFR 147.136

Other Arguments:

☐ Similar treatment was previously approved

☐ The plan has approved this for other members

☐ State law requires coverage for this condition/treatment

☐ Other: ______________________________________________

Section 4: Detailed Argument

Statement of Medical Necessity

Diagnosis and Medical History:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Why This Treatment is Medically Necessary:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Conservative Treatments Already Tried (and why they failed):

Expected Outcome of Requested Treatment:

_______________________________________________________________________________

_______________________________________________________________________________

Consequences of Denial:

_______________________________________________________________________________

_______________________________________________________________________________

Section 5: Supporting Medical Evidence

Clinical Guidelines and Literature

The following clinical guidelines support the medical necessity of this treatment:

☐ American Medical Association guidelines
☐ Specialty society guidelines: ______________________________________________
☐ FDA-approved indications
☐ Peer-reviewed journal articles (citations below)
☐ UpToDate or similar clinical decision support
☐ Medicare National Coverage Determination
☐ Medicare Local Coverage Determination
☐ Other: ______________________________________________

Specific Citations:

1. ___________________________________________________________________________

2. ___________________________________________________________________________

3. ___________________________________________________________________________

Section 6: Documentation Submitted

Documents Included with This Appeal

From Treating Physician:
☐ Letter of Medical Necessity
☐ Treatment notes/medical records
☐ Test results (labs, imaging, pathology)
☐ Treatment plan
☐ Peer-reviewed literature supporting treatment
☐ Clinical guidelines reference

Denial Information:
☐ Copy of denial letter
☐ Explanation of Benefits (EOB)
☐ Prior authorization denial (if applicable)
☐ Previous correspondence with insurer

Plan Documents:
☐ Relevant pages from Summary Plan Description
☐ Certificate of Coverage excerpts
☐ Evidence of Coverage excerpts

Other:
☐ Prior authorization approval (if applicable)
☐ State law citations
☐ Prescription (if medication)
☐ Other: ______________________________________________

Section 7: Physician's Supporting Statement

Statement from Treating Physician

Physician Name: ______________________________________________

Specialty: ______________________________________________

NPI: ______________________________________________

Contact: ______________________________________________

Physician's Statement (or attach separate letter):

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Physician Signature: ______________________________________________

Date: ______________________________________________

Section 8: Legal and Regulatory References

Applicable Law

This appeal is made pursuant to:

Federal Law:
- Affordable Care Act Section 2719 (internal appeals requirements)
- 45 CFR 147.136 (internal claims and appeals processes)
- 29 CFR 2560.503-1 (ERISA claims procedures)
- Mental Health Parity and Addiction Equity Act (if applicable)
- No Surprises Act (if applicable)

Your Obligations Under Law:

1. This appeal must be reviewed by individuals who were not involved in the initial denial
2. The review must be conducted by a healthcare professional with appropriate expertise
3. You must identify the medical experts whose advice was obtained (without regard to whether it was relied upon)
4. You must provide free copies of all documents relevant to the claim upon request
5. You must provide a decision within the timeframes specified by law

Section 9: Request for Information

Pursuant to 45 CFR 147.136 and 29 CFR 2560.503-1, I request:

☐ Complete copy of claim file
☐ All internal rules, guidelines, or protocols relied upon
☐ Explanation of scientific/clinical judgment used
☐ Identity and credentials of reviewers/medical experts consulted
☐ Specific plan provisions on which denial is based
☐ Any clinical criteria used in the determination

Section 10: Request for Action

I respectfully request that [Insurance Company Name]:

1. Overturn the denial and approve coverage for [service/treatment]

2. Process and pay the claim at the applicable benefit level

3. If this is a pre-service denial, issue authorization immediately

4. Provide written decision within the timeframe required by law:
   - Pre-service: 30 days
   - Post-service: 60 days
   - Urgent: 72 hours (or 24 hours for urgent pre-service)

5. If denial is upheld, provide detailed explanation of:
   - Specific reasons for upholding denial
   - Clinical rationale
   - Plan provisions relied upon
   - My right to external review
   - How to request external review

Section 11: Contact Information

Member Contact Information:

Authorized Representative (if applicable):

☐ Designation of Representative form attached (CMS-1696 or equivalent)

Section 12: Member Certification

I certify that the information provided in this appeal is true and accurate to the best of my knowledge. I authorize release of any medical information necessary to process this appeal.

Member Signature: ______________________________________________

Printed Name: ______________________________________________

Date: ______________________________________________

Appeal Tracking

Next Steps If Appeal Is Denied

If your internal appeal is denied, you have the right to:

1. Request External Review - An independent third party will review the denial
2. File Complaint with your state insurance commissioner
3. Contact Consumer Assistance Program - Many states have programs to help
4. Seek Legal Counsel - You may have rights under ERISA or state law

External Review Deadline: Typically 4 months (120 days) from final internal appeal denial

Resources

• DOL EBSA: https://www.dol.gov/agencies/ebsa
• CMS Consumer Information: https://www.cms.gov/CCIIO/
• Healthcare.gov Appeals: https://www.healthcare.gov/appeal-insurance-company-decision/
• State Insurance Department: [State-specific link]

This template is provided for informational purposes only and does not constitute legal advice. Consult with a healthcare or ERISA attorney for specific legal guidance.