Preparing for your appeal
Use the Appeal Worksheet to gather information. Note:
- Your contact information (name, mailing address, phone number)
- Contact information for the person representing you, if applicable (such as an attorney, parent or guardian, provider, or person who is acting as your attorney)
- Name of the company or group providing the health plan
- Policy number and, if it applies, claim numbers
- If your plan is through your employer, the name and location of your employer
- Names of doctors or providers who provided care or who gave an opinion or recommendation
Documents you may want to gather to help you with your appeal:
- Your most current benefits booklet.
- All documents related to the situation you are appealing.
- Ask what criteria the insurance company used to base its decision on and to send you a copy of that document. You can share this with your doctor so the doctor can provide the information needed for the service to be covered.
- Any explanation of treatment or services from your medical provider's office.
- Any denials (also known by your health plan as adverse benefit determinations.
- Any research to support your opinion that the denial should be overturned (you can ask your insurance company customer or membership services for the criteria they used as the basis of your denial).
Getting your documents
Gather all medical records and other supporting documents early on in the appeals process. Ask your doctor to help you gather the information you need. If you ask the insurance company for the criteria it used in denying your claim, you can give that to your doctor when you ask for help.