Organize Your Materials
What papers do I need?
Keep copies of all information related to your claim and the denial. This includes information your insurance company provides to you, and information you provide to your insurance company, such as:
- The Explanation of Benefits (EOB) forms or letters showing what payment(s) or service(s) were denied
- A copy of the request for an internal appeal that you send to your insurance company
- Any additional information you send to the insurance company (such as a letter or other information from your doctor)
- A copy of any letter or form you are required to sign, if you choose to have your doctor or anyone else file an appeal for you.
- Keep a diary of phone conversations you have with your insurance company or your doctor that relate to your appeal (include the date, time, name, and title of the person you talked to, as well as details about the conversation)
Keep your original documents and submit copies to your insurance company. You will need to send your insurance company the original request for an internal appeal, and your request to have a third party (such as your doctor) file an internal appeal for you. Make sure you keep copies of all documents for your records.
What kinds of denials can be appealed?
You can file an internal appeal if your health plan won’t pay some or all of the cost for health care services you believe should be covered. The plan might issue a denial because:
- The benefit is not offered under your health plan
- Your medical problem began before you joined the health plan
- You received health services from a health provider or facility that is not in your health plan’s approved network
- Your health plan determines the requested service or treatment is “not medically necessary”
- Your health plan determines the requested service or treatment is an “experimental” or “investigative” treatment
- You are no longer enrolled or eligible to be enrolled in a health plan
- Your health plan revokes or cancels your coverage, going back to the date you enrolled, because the insurance company claims you gave false or incomplete information when you applied for coverage