Have you had a health insurance claim denied? You may be feeling stressed, even overwhelmed. But don’t fret. You still have a solid option to appeal your denied insurance claims. Namely, writing a letter of appeal to insurance company offices.
Writing a letter of appeal for insurance claim rejection can be a daunting task, but with the right approach, you can get your claim reviewed (and hopefully approved!) In this article, we will discuss how to write an appeal letter to insurance company adjusters step-by-step, and we’ll explain how to get help with insurance appeal claims if you need additional assistance.
Why might you need a letter of appeal for insurance claims?
Most likely, one of these two things has happened. Either you have had a medical procedure for which your insurance has refused to pay, or you filed a superbill for out-of-network reimbursem*nt, and the insurance claim was denied. In both cases, you can appeal the denial.
A lot of articles online leave it at that: appeal your denial. But there’s more to it. We want to shed some light on how to write a letter of appeal to insurance companies, since there just aren’t enough resources out there for patients.
The stakes are quite high. According to a study by Change Healthcare, about $262 billion worth of insurance claims are initially denied each year. A lesser-known statistic from the same report is that 63% of those claims were recoverable. That’s a pool of $165 billion that claims appeals can access. If you have had an insurance claim denied, chances are actually well above half that you can still be reimbursed.
How to write an appeal letter to insurance company appeals departments
Let’s break the process of writing an appeal letter down into bite-size pieces to make it easier. Remember that a good portion of the work happens before you write anything. If you take care to gather and organize all the information you’ll need, the letter will practically write itself!
Step 1: Gather Relevant Information
The first step in writing a letter of appeal for insurance claims is to gather all the information related to your claim. This includes the original claim form, any supporting documentation, and the letter of rejection from the insurance company. Make sure to read over the letter your insurer sent when they denied your insurance claim. Review the reason for the rejection and identify any errors or missing information so you do not make the same mistake twice.
It’s a good idea to contact your health insurer to ask them for more information about the denial. Call the customer service number on the back of your insurance card. Make sure you understand the correct process to filing the appeal with your insurer and deadlines for doing so!
If the original claim was made using a superbill for an out-of-network expense, review our What Is a Superbill post for a breakdown of all the information a health insurer needs to process the claim. If a necessary detail was omitted from your superbill, you may need to ask your provider for a new one.
If your claim was made by an in-network provider, you should contact them to ask them to correct errors and resubmit the claim to your insurance.
Step 2: Organize Your Information
Once you have gathered all the necessary information, it is important to organize it in a logical and easy to understand manner. This will make it easier for the insurance company to review your appeal and understand your case. We recommend organizing things in the following manner.
1. Error #1
- Insurer’s reason for error
- Your proposal for amending the error
- Any supporting evidence and/or documentation
2. Error #2
- Insurer’s reason for error
- Your proposal for amending the error
- Any supporting evidence and/or documentation
3. Error #3
- (etc.)
Step 3: Write a Polite and Professional Letter
Keep in mind that a letter of appeal is a formal document and should be written in a polite and professional manner. Begin the letter by addressing the insurance company and the person who denied your claim. State the reason for your letter and provide a brief overview of your case.
Overall, maintain a calm and respectful tone. Although you may be frustrated with the rejection, letting that emotion out in your letter will not help your chances of winning the appeal. It may help to ask a friend or family member to look over the letter before you send it. Ask them to double-check that your tone is polite enough.
Step 4: Include Supporting Documentation
Include copies of any supporting documentation that you have gathered, such as medical records, diagnoses, bills, and test results. Make sure to reference these documents in the letter and explain how they support your claim. Don’t forget to retain a copy of these documents for your own records!
If you organized your support documents well in step 2, this step should be a breeze.
Step 5: Explain the Error or Omission
If your claim was denied due to an error or omission on your part, explain this in the letter and take ownership for it. Denying responsibility for the error will not help your chances with the appeal. Do your best to provide any additional information or explanation that may help clarify the situation.
Step 6: Request a Review
Formally request that the insurance company review your case and provide an explanation of the decision. Indicate that you are willing to provide any additional information or documentation that may be needed.
Step 7: Conclude the Letter
Conclude the letter by thanking the insurance company for their time and consideration. Provide your contact information, including your telephone number and email address, in case the insurance company needs to reach out to you.
Step 8: Follow Up
After you have sent the letter of appeal, it is important to follow up with the insurance company. You can follow up by telephone or email to inquire about the status of your case. It's also a good idea to keep detailed notes of any correspondence or conversations you have with the insurance company. (We suggest keeping everything pertaining to your claim in a single digital folder.)
Sample appeal letter to insurance company from providers
In many cases, your provider may opt to write the letter of appeal for your insurance claim on your behalf. They may choose to do so because they have something specific to explain to the insurer, or because the services rendered were highly technical and discussing them requires medical expertise.
Regardless of why they are doing it, providers can customize the following template to craft their own appeal letter.
Sample Letter Template of Denial Appeal from Providers
Sample appeal letters to insurance company from patients
For patients requesting a claims denial reconsideration, insurance appeal letter templates can save a great deal of time. Because your reasons for appealing a denial may vary, we have included a general appeal template as well as two more specific templates for letters from patients below. Feel free to copy the letter most relevant to your situation as your starting point.
Sample Appeal Letter for General Claims Denials
Sample Appeal Letter for Denial of Experimental Treatment
Sample Appeal Letter for a ‘Not Medically Necessary’ Denial
Stay persistent!
Writing a letter of appeal for insurance claim rejections can be a challenging task, but with this guide, you can increase your chances of getting denied insurance claims reviewed and approved. Remember to be polite and professional, provide all the necessary information and documentation, and follow up with the insurance company. With a well-written letter of appeal and a healthy amount of persistence, you have a chance at getting your claim approved and receive the benefits you are entitled to.
