Begin with the instructions
What to check before you draft
Read the denial notice and EOB together. Note the claim or reference number, the service or item involved, the stated reason for denial, and any dates or appeal instructions. If the notice uses a code, check the explanation provided with it.
Review your current plan materials for the appeal process and submission method. Deadlines and requirements can vary, so use the dates in your notice and plan instructions rather than a general timeline. If something is unclear, contact the insurer or plan administrator listed in those materials and ask what applies to your claim.
Gather records that relate to the stated denial reason. The official instructions for your plan should tell you whether a particular form or supporting document is required.
A simple structure
A general appeal letter outline
Follow any form or format your plan requires. If a letter is appropriate, these points can help keep it organized:
- 1Identify the claim and service. Include the information the plan requests, such as the member, claim, date of service, or reference number.
- 2State the denial reason. Refer to the reason as it appears in the notice, so the reviewer can see which decision you are asking them to review.
- 3Explain your request in your own words. Describe what you believe should be reviewed and why, using facts you can support from your records.
- 4Point to supporting records. Name the relevant documents and attach copies as directed by the plan. Keep original records for yourself unless the instructions say otherwise.
- 5Make the requested next step clear. Ask for the review described in your plan materials and include the contact information or signature the instructions require.
Gather relevant records
Document checklist
Depending on the reason for the denial, these records may help you prepare. This is an example list, not a universal requirement:
- The denial notice and explanation of benefits (EOB)
- Current plan materials and the appeal instructions that came with the notice
- Claim, billing, and service records related to the denied item or service
- Relevant medical records or information from a treating provider, if applicable
- Prior-authorization records or earlier messages about the claim, if relevant
- Copies of letters, forms, and other records you plan to submit
Only send records relevant to your request, and use the plan’s instructions to confirm what to include and how to protect personal information.
Keep a paper trail
Submit the letter and keep records
- Use the address, portal, fax, or other method specified in your current plan instructions. Confirm any deadline directly from your notice or plan materials; if you are unsure, ask the insurer or plan administrator.
- Keep a copy of the letter and every attachment. Save submission receipts, delivery confirmations, or portal confirmations that show what was sent and when.
- Record dates and details of calls or messages, and save the response to your request with the rest of the claim documents.
Choose an educational next step
Free orientation and the separate Appeal Kit
CairnClaim’s free, three-question orientation is an educational tool for exploring what to check next. It does not submit an appeal or decide which rules apply to a particular claim.
The Appeal Kit is a separate paid product for organizing one appeal. Its current details and offer are on the pricing page. You can read this guide and use the free orientation without buying the kit.
CairnClaim does not provide legal or medical advice and cannot promise an appeal outcome. Your denial notice, current plan materials, and insurer or plan administrator are the sources for instructions that apply to your situation.