Dealing with a denied insurance claim can be frustrating. But before giving up, filing an appeal is worth a shot. A well-written appeal letter has the potential to get your claim reviewed and approved.
Crafting an effective insurance appeal letter may seem daunting at first. But following key steps can set you up for success.
In this comprehensive guide, we’ll walk through the entire process of writing an appeal letter to insurance companies.
There are two main reasons your insurance claim may be denied:
Appealing denied claims is very common. According to statistics:
The odds are in your favor that filing an appeal is worthwhile. Let’s look at how to maximize your chances of success.
Follow these key steps when drafting an insurance appeal letter:
Start by gathering information related to your denied claim:
Having these materials close at hand is crucial for crafting your appeal.
Most insurers have strict appeal deadlines, often 180 days from the denial. Verify the timeline outlined in your denial letter and submit the appeal as soon as possible.
Meeting deadlines is critical. Late appeals may not be accepted, eliminating your chance for review.
Insurance appeals should follow standard business letter formatting:
Maintaining a formal format helps show this is an important (and legally binding) document.
Early in your letter, provide key details to identify the specific claim you’re appealing:
Providing clear identifying details allows the insurer to quickly pull your file and review the correct claim case.
Specify the exact reason given by the insurer when your claim was denied. For example:
This helps demonstrate your understanding of the denial.
This is the key section where you make your case for overturning the denial. Some tips:
The goal is to clearly demonstrate why the original denial was unwarranted and should be overturned. Back up statements with evidence and documentation.
Make sure to list or include any documents that support your appeal case, such as:
Documents provide objective evidence strengthening your position.
Wrap up your appeal letter with a specific call to action. For example:
Spell out exactly the outcome you are seeking – approval upon review of your appeal.
Thank the insurer for taking the time to thoroughly re-review your claim. Provide your contact information and indicate you will follow up soon.
Being courteous sets a positive tone. Follow up within 2 weeks if you do not receive a response. Tracking your appeal and holding insurers accountable is key.
We’ve included templates you can adapt when drafting your own insurance appeal letter:
Insurance Company Name
Address
RE: Appeal for Denial of Claim #123456
To Whom It May Concern:
I am writing to appeal the denial of coverage for my recent claim #123456. This claim was for an MRI ordered by my neurologist Dr. Jane Smith on 5/15/2022.
This MRI was denied on the basis that it was “not medically necessary.” However, as outlined in my insurance policy under Section 3.2, diagnostic tests related to chronic health conditions are covered when ordered by an in-network provider.
I have suffered from chronic migraines for the past 2 years, which my neurologist has been treating. She ordered this MRI to further evaluate the cause of my symptoms, as detailed in the letter I have included from her.
Based on my policy provisions and this supporting medical evidence, I believe this MRI should be covered as medically necessary care. Please reconsider your denial and process my claim. I have included a copy of my original claim and denial letter for reference.
Please contact me at 123-456-7890 or [email protected] if you require any additional information. I look forward to your response approving my claim upon review.
RE: Appeal for Denial of Claim #987654
Dear Claims Manager:
I am writing regarding denial of my claim #987654 for a sleep study. This claim was denied on the basis of the sleep study being an “excluded procedure.”
However, my policy under Section 1.3 clearly states outpatient diagnostic procedures are covered when medically required. There is no exclusion for sleep studies stated. I have included the relevant page highlighting this coverage provision.
My physician required this sleep study to diagnose a potentially serious sleep disorder impacting my health. As demonstrated in the attached letter and clinical notes from Dr. Smith, this test was medically necessary.
Based on my policy terms and this supporting evidence, the denial appears unwarranted. I formally request you re-review and reconsider your denial of my claim. Please contact me at 555-1234 with any questions or requests for additional details. I look forward to your timely response.
These templates cover two common denial scenarios. Modify details to match your specific situation. The key is backing up your case with documentation.
If your appeal is denied, you may choose to pursue additional appeals. However, most insurers limit this to 2-3 total reviews.
If you ultimately exhaust the appeals process with no success, consider contacting your state’s insurance regulator to file an external complaint. They may be able to resolve the issue and get your insurer to pay the claim.
Seeking legal assistance from an insurance lawyer is another option. An experienced attorney can advise you on the merits of your case and prospects for success before investing in further appeals.
With the right approach, you can successfully appeal many insurance claim denials. Don’t hesitate to seek assistance if your own efforts are unsuccessful.
What is an example of appeal?
Examples of appeal in a Sentence The mayor made an appeal to the people of the city to stay calm . We made a donation during the school’s annual appeal. She helped to organize an appeal on behalf of the homeless. My lawyer said the court’s decision wasn’t correct and that we should file for an appeal.
How do I write a grievance letter to an insurance company?
My policy number is ______________. My complaint concerns______________ [The reason for your complaint, followed by your explanation of what happened ]. To solve my problem, I would like _____________ [The specific action you want the plan to take]. I look forward to your reply and a resolution of my complaint.