How to Write an Effective Insurance Appeal Letter

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.

Why File an Insurance Appeal?

There are two main reasons your insurance claim may be denied:

• Processing Errors – Mistakes happen. Claims can be denied incorrectly. Appealing gives the insurer a chance to fix errors.

• Lack of Information – Claims are often denied due to missing documentation. An appeal allows you to provide additional details.

Appealing denied claims is very common. According to statistics:

• Up to 30% of insurance claims are denied initially.

• Of those denied claims, up to 75% are overturned upon appeal.

• Appeals result in more than $4 billion in recovered claim payments annually.

The odds are in your favor that filing an appeal is worthwhile. Let’s look at how to maximize your chances of success.

How to Write an Appeal Letter: Step-by-Step

Follow these key steps when drafting an insurance appeal letter:

Step 1: Gather Background Information

Start by gathering information related to your denied claim:

• The denial letter from the insurance company. Review the exact reason given for declining your claim.

• The Explanation of Benefits (EOB) form showing the denial.

• Your original claim submission and any related documents, such as medical bills or records.

• Your insurance policy. Check for coverage details relevant to your claim.

Having these materials close at hand is crucial for crafting your appeal.

Step 2: Act Quickly

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.

Step 3: Use the Proper Format

Insurance appeals should follow standard business letter formatting:

• Your contact info and date at the top

• Insurance company’s address below your info

• A formal salutation (e.g. Dear Ms. Smith)

• Professional letter body, typically 3-5 paragraphs

• Closing statement with request for review

• Sign your name at the bottom

Maintaining a formal format helps show this is an important (and legally binding) document.

Step 4: Identify Yourself and Your Claim

Early in your letter, provide key details to identify the specific claim you’re appealing:

• Patient name and DOB

• Insurance member ID #

• Date of service for the denied claim

• Name of the provider (doctor, hospital, etc.)

Providing clear identifying details allows the insurer to quickly pull your file and review the correct claim case.

Step 5: State the Reason for Denial

Specify the exact reason given by the insurer when your claim was denied. For example:

• Procedure not medically necessary

• Services not covered under policy

This helps demonstrate your understanding of the denial.

Step 6: Explain Why the Denial Should be Reversed

This is the key section where you make your case for overturning the denial. Some tips:

• Cite policy provisions – Reference specific sections in your policy that support coverage. Quote language directly if possible.

• Include medical evidence – Have your doctor provide documents explaining the medical necessity of the treatment or service.

• Dispute reasons – If the denial states services are not covered, clarify why you believe they should be covered based on your policy’s actual provisions.

• Correct errors – If denial is based on incorrect details, such as pre-existing condition, provide documents to correct the record.

The goal is to clearly demonstrate why the original denial was unwarranted and should be overturned. Back up statements with evidence and documentation.

Step 7: List Supporting Documents

Make sure to list or include any documents that support your appeal case, such as:

• Letter from physician explaining medical necessity

• Relevant medical records

• Sections of insurance policy document supporting your claim

• Independent research or clinical guidelines supporting treatment

Documents provide objective evidence strengthening your position.

Step 8: Close with a Call to Action

Wrap up your appeal letter with a specific call to action. For example:

• “Based on the information provided, I request that you review and reconsider your denial of my claim.”

• “Please thoroughly review these details and contact me with any questions. I look forward to receiving your response approving my claim appeal.”

Spell out exactly the outcome you are seeking – approval upon review of your appeal.

Step 9: Express Appreciation and Follow Up

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.

Appeal Letter Templates

We’ve included templates you can adapt when drafting your own insurance appeal letter:

Medical Necessity Appeal

Date

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.

Thank you,

Jane Doe

Procedure Not Covered Appeal

Date

Insurance Company
Address

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.

Sincerely,
John Doe

These templates cover two common denial scenarios. Modify details to match your specific situation. The key is backing up your case with documentation.

Getting Help with Insurance Appeals

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.

Key Takeaways

• Filing an insurance appeal is very common – millions are submitted each year.

• Most denials are overturned when appealed, making it worth the effort.

• Allowing deadlines to lapse can eliminate your appeal rights, so act quickly.

• Effective appeals cite policy provisions and include documentation.

• Follow up persistently if your appeal is not initially approved.

With the right approach, you can successfully appeal many insurance claim denials. Don’t hesitate to seek assistance if your own efforts are unsuccessful.