OHA: How to Write an Appeal Letter

Coverage Problems

Write an Appeal Letter

After you have gathered all your information and have a basic knowledge of the illness and the insurance plan, you are ready to start the appeals process. The insurer is required to include in any adverse determination the specific reason for the denial and must, should you request them, provide all of the documents and material that was used in making their decision. This may include the medical criteria for your condition. It is very helpful to request these criteria from the insurer before you submit your appeal so that you can address each of the required elements.

Your appeal should include:

  • An appeal letter.
  • A letter from your doctor (and specialist if appropriate) addressing specifics of your case.
  • Any pertinent information from your medical records that would support your case

The Appeal Letter should include:

  • Your plan identification numbers (policy number, group number, claim number).
  • The reason for the denial that they explained in the denial letter.
  • A brief history of the illness and necessary treatment.
  • Why you believe the decision was wrong.
    • This would be an appropriate place to include the plan's criteria and support each element with facts from your medical record and/or the doctor's letter.
  • What you are asking the managed care plan to do.
  • A request for the insurer's file on the claim.