How to write an appeal letter to health insurance company

Your appeal rights when your health insurance company says no to a treatment or a bill

This short video explains what you can do if your health insurer says no to a treatment or bill dispute.

You can win an appeal, but it takes some work. First, read the denial letter. Why was coverage denied? What's the appeals process and timeline?

If it's a billing or claims-processing error, call your medical provider's billing office and ask them to clear things up with the insurer. If a bill is due during your appeal process, consider these suggestions.

If it isn't a billing or claims-processing error, you'll need to appeal to overturn it. Below are some suggestions that might help.

For continued care in an urgent situation

A health plan must provide continued coverage pending the outcome of an appeal. It can't reduce or stop benefits for an ongoing course of treatment without providing you advance notice and an opportunity for review (RCW 48.43.535(9) (leg.wa.gov).

Note: if you lose the appeal, you may be responsible for those medical costs.

Tips for filing your appeal

• Identify your type of insurance coverage and find out if you have a group, individual or government-sponsored plan, and which law your plan follows.
• For Medicare and other plans like TRICARE, Apple Health for Kids, etc. you will need to follow their appeals processes.
• Find out the deadline for an appeal. Where do you send it? These are usually in the denial letter. If not, ask your insurer.
• Determine if you have a non-grandfathered plan or a grandfathered plan and what your appeal options are for your particular plan. If you're not sure which kind of plan you have, call your carrier and ask them.
• Keep a log of every call, email and letter. Here's a printable example (PDF, 641.36 KB) of a contact log.
• Gather your medical records. If you don't have them, ask your medical provider for copies. Here's an example letter. (Word, 32KB)
• Appeal letters should be to the point, timely and specific about the outcome you seek. Here's an example appeal letter (Word, 24KB) and a list of common reasons for a denial and example appeal letters you can use.
• It helps to have a supporting letter from your medical provider. Give them a copy of the reason for denial.
• Don't be afraid to call, especially if someone said they would get back to you and they didn't.
• Send copies of documents, not originals, and send them as certified mail.

What is an independent review organization (IRO)?

If your health plan upholds a claim denial after you completed its appeals process, you can request an external review of your appeal using an independent review organization (IRO). This option should be outlined in the determination letters you receive from your insurer, or you can contact your health plan's customer service line to get more information about asking for an external review. An IRO isn’t affiliated with your insurance company and doesn’t have a financial interest in the outcome of your case.

The IRO can either uphold or overturn the insurance company's position. Once an IRO reviews an appeal, its decision is binding. All IROs in Washington state must register with and be certified by the Office of the Insurance Commissioner. 

Our IRO search tool allows you to search IRO decisions. You can modify your search based on a number of factors, including cases involving your insurance company, diagnosis, treatment, outcome or reason for the appeal.

You may want to also file a complaint

Whether or not you file an appeal, you may also want to file a complaint with our office. The appeals and complaint processes are different, and can take place simultaneously without affecting each other. If in doubt, you may want to try both avenues to resolve your issue.

Medical claim denial is arguably one of the worst things dreaded by healthcare providers. When a medical claim gets denied, the insurance company is like telling you, “We know you did your job, but we can’t pay you.”

At some point, every healthcare organization will need to send an appeal letter to insurance providers. However, healthcare organizations do not have the luxury of time for sending numerous appeal letters. Many of these organizations don’t know how to create an effective appeal letter.

Hence, we will provide you with a short and comprehensive guide on writing an insurance appeal letter. This guide will teach you what an appeal letter is and show you a few sample letters for understanding it better. Finally, you will also get some handy tips on how you can optimize your appeal letter printing and delivery.

What is An Insurance Appeal Letter?

An insurance appeal letter is a healthcare organization’s letter to an insurance company when a patient’s medical claim gets rejected. It is also called an appeal letter for medical claim denial, and every healthcare provider dreads having to write one.

When a medical claim by one of your patients gets denied, it effectively means that your payment is on hold. No matter how hard you try, it is inevitable for healthcare providers to function without once having to send an insurance appeal letter.

In other words, sending appeal letters is an inevitable part of a healthcare organization. Hence, healthcare providers must learn to write an effective appeal letter for medical claim denials. A well-crafted appeal letter can benefit your healthcare organization and your valuable patients.  

The best and most convenient way to create an insurance appeal letter is to go through different appeal letters samples. Hence, we will provide you with three different hospital appeal letter samples that can help you create your unique appeal letter.

Hospital Appeal Letter Sample 1

[Date]

[Name]

[Insurance Company Name]

[Address]

[City, State, and ZIP Code]

Re: [Patient’s Name]

       [Insurance Coverage Type]

       [Group/Policy Number]

Dear [Insurance company contact person’s name]

I hope you accept this letter as [Patient’s Name] appeals to your insurance company’s decision to deny the medical claim for [specify the healthcare procedure for which the claim was denied]. If my understanding of the letter of denial dated [Date on denial letter] is correct, you denied the medical claim for the [name the healthcare procedure/service] because:

[State the specific reason for the denial as per the denial letter]

As you are already aware, [patient Name] was diagnosed with [disease] on [Date]. I want to inform you that Dr. [name] strongly believes that the [Name of the medical procedure] will significantly benefit [Patient’s Name] health. Please look at the letter from Dr [Name] that explains the medical history of [Patient’s Name].

I would also like to inform you that [Patient’s Name] believes you did not have all the relevant information during the initial review. Hence, [Patient’s Name] has also provided a letter from Dr. [Name] from [Name of the doctor’s healthcare organization] enclosed with this insurance appeal letter. Dr. [name] is a renowned specialist in [name specialty], and his letter discusses the procedure in detail.

In addition to this, this insurance appeal letter also includes [Patient’s Name]’s medical records and several medical journals that explain the procedure and its results. [Patient’s Name] would like to request you reconsider your previous decision based on the new information provided with this letter. The Patient also requests that you allow full medical coverage for the procedure as Dr. [name] outlined.

Finally, I would like to inform you that [Patient’s name] treatment is scheduled to start on [Date]. If you require any more information regarding the matter, please do feel free to contact [Patient’s Name] at [phone number]. [Patient’s Name] looks forward to hearing back from you soon.

Sincerely,

[Your Name]

Hospital Appeal Letter Sample 2

[Date]

[Name]

[Insurance Company Name]

[Address]

[City, State, and ZIP Code]

Re: [Patient’s Name]

       [Insurance Coverage Type]

       [Group/Policy Number]

Dear Madam or Sir,

This insurance appeal letter urges you to reconsider your decision to deny [Patient’s Name] ‘s request for [healthcare procedure/service]. I want to inform you that the [patient’s name] doctor supports that the [healthcare procedure/service] is the best option for her/him. [Patient’s Name] would also like to say that the right to access this care is guaranteed by [cite applicable state health law]. 

Along with this  insurance appeal letter, you will also find other documents enclosed, such as:

• • A written treatment plan for [Patient’s Name] ‘s attending doctor, Dr. [name].
  • A supporting letter from the same Dr. [name] detailing the hospitalization costs of the Patient.
  • A copy of [state name] state regulation requiring [healthcare procedure/service].

I hope you review this appeal at the earliest. Please let me know if you need any additional information. [Patient’s Name] looks forward to hearing from you.

Sincerely,

[Your Name]

[Your Address]

Hospital Appeal Letter Sample 3

[Date]

[Name]

[Insurance Company Name]

[Address]

[City, State, and ZIP Code]

Re: [Patient’s Name]

       [Member ID #]

       [Reference # on Explanation of Benefits]

       [Your Date of Birth]

Dear Madam or Sir,

My name is [Patient’s Name], and I am a longtime policyholder of [insurance company name]. I am writing you this letter to file an appeal regarding the denial of my medical claim for [healthcare procedure/service]. I had received an Explanation of Benefits stating [denial reason stated in the letter] dated on [Date on the letter].

If you go through my previous medical claims, you will find that I was diagnosed with [Patient’s health diagnosis] on [Date]. The truth is that my everyday life is significantly impacted by [health problems/symptoms]. Dr. [name] is currently treating my ailments at [hospital or healthcare organization]. I am also attaching a letter of medical necessity from Dr. [Name] with this insurance appeal letter. 

Dr. [name] has outlined why [medical procedure] is beneficial for me. He/she also states that “[statement supporting the treatment].” Please refer to the full letter for more details concerning my medical history. Additionally, I have also included supplemental materials explaining the nature of the medical procedure. You can even find other information, such as the procedure’s efficacy for my condition.

I hope you get to thoroughly review the documents enclosed with this insurance appeal letter and reconsider your initial decision. The treatment was necessary for my health, and I hope you come to this understanding and allow coverage of [healthcare procedure]. If you need any further supporting information for making a favorable decision, please do not hesitate to contact me at [Patient’s number].

You can also contact my physician at his/her number [doctor’s number]. Finally, I would like to thank you for your attention in this matter. I’d very much appreciate your prompt response to this appeal.

Respectfully Your,

[Your Name]

[Your Address]

Enclosures:

1. 1. Explanation of Benefits document dated [Date]
   2. Letter of Medical Necessity from the doctor
   3. Medical Records
   4. Documents explaining the medical procedure and its efficacy
   5. Supporting Journal Articles

CC: [Name of Treating Doctor]

Creating a medical appeal letter is still confusing to many healthcare providers. Sometimes, even the seasoned healthcare provider doesn’t do the best job writing the appeal letter. Here are some handy tricks to create an effective appeal letter to medical insurance providers.

Tip 1: Use A Hospital Appeal Letter Sample To Save Time

Many patients and healthcare organizations often overlook the time perspective of medical claim denials. Doctors already have a busy life, and most of them still wish they could get more time with their patients. Hence, you can imagine how little time they have for the Patient’s insurance appeal letter.

Furthermore, the healthcare industry has one of the highest burnout rates for working professionals. The main takeaway is that healthcare professionals and organizations rarely have enough time to send several appeal letters.

Even if healthcare organizations could magically create more time out of thin air, they would use it for their patients. So, what is the silver lining we are trying to make here? Using a tried and tested hospital appeal letter sample and an automated direct mail system can help you speed up the process significantly.

Use The Data From Medical Claim Denial Letter

Whenever you receive a medical claim denial letter, you can get some basic information for your appeal letter from it. For example, the claim denial letter contains essential details like 

• Identity of the insurance provider
• Claim Adjustment Reason Code (CARC)
• Date of claim denial

Although these details may not sound like much, it is good enough for your healthcare organization as it usually has the other information. So, all you have to do is put the two together and create a comprehensive insurance appeal letter.

Tip 2: Incorporate Your Branding And Enhance Professionalism

When it comes to the healthcare industry, the branding aspect usually takes a back seat, which is not an ideal practice. Again, it is perfectly understandable that healthcare providers focus all their efforts on serving their patients. However, that does not mean you have to ignore branding altogether.

Your medical appeal letter is a great way to give precedence or, at least, more significance to your branding. Often, the doctor’s name and title alone on a mailer are enough for anyone to understand its essential nature. However, with appeal letters, every one of them is from a doctor’s office, and it loses its charm.

Use Branding To Capture The Reader’s Attention

Make your appeal letters stand out by incorporating your brand’s design aspects. You can use these design elements throughout your mailer. Whether you want to take a subtle approach or a more rudimentary one is entirely up to you.  

A basic guideline for incorporating your branding into the insurance appeal letter is using your organization’s logo and color pallets. Finally, never make the mistake of thinking that the design and formatting of your appeal letter do not make a difference.

Tip 3: Safely Store Your Records and Tracking Information

Another thing to note when sending an appeal letter for your healthcare organization is always to maintain accurate records. The record should include 

• A copy of your appeal letter
• Time and Date of when you sent it
• Time and Date of the insurance company receiving your letter

Among the points listed above, the last one is critical. You must have the tracking information of your letter regardless of whether you send it online or offline. It is relatively easy to track your medical appeal letter with online channels.

But if you want to track offline letters, we suggest that you use an advanced print and mail automation tool like PostGrid. It enables you to better track all your direct mail, including your appeal letters, and gain valuable insights.

Consider Additional Time Required For Follow-Ups

Insurance companies are known for their quick replies. They do not respond immediately to your insurance appeal letter, and you can almost always expect some delays. With advanced tracking, you get a glimpse into how complex the process is. More importantly, you get an idea of the time required to get a reply from the insurance provider.

Keeping accurate records of your appeal letters enables you to send follow-up letters just at the right time. As a result, you can minimize the time required to get a response from different insurance providers.  

Tip 4: Use An Automated Print and Mail System

As we have already mentioned, one of the biggest challenges healthcare providers face when sending appeal letters is the lack of time. Automation is the ultimate solution to save a significant amount of time regardless of when or where you employ it.

You can use an advanced print and mail solution like PostGrid for printing personalized medical appeal letters. Furthermore, you can also use letter templates to speed up the process. PostGrid also comes with HIPAA certification, which means it can securely use your patient data without any risks.

You also get advanced tracking and insights from PostGrid, which ultimately helps you optimize your direct mail communication. Hence, you can ensure that your appeal letters and other documents such as follow-up mail, patient statements, and more are always on time.

Medical claim denials are not something healthcare organizations look forward to. It can lead to many financial problems and take a long time to get sorted. Hence, healthcare providers must do everything to optimize their insurance appeal letter delivery.

Using a medical appeal letter sample template and an advanced direct mail tool like PostGrid can do wonders for your organization. With an advanced tool like PostGrid, you can bulk print appeal letters using different letter templates. 

You can also personalize your letters using PostGrid’s HIPAA-compliant software. Apart from optimizing your appeal letter printing and delivery, PostGrid can help you streamline your whole direct mail operations. Hence, everything from appeal letter follow-ups to regular patient statement printing is optimizable with PostGrid.

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