November 23, 2017

 
Internal Appeal Letter 

This internal insurance appeal letter template is versatile enough to be tailored to your own circumstances as are the ones that follow. Feel free to cut, paste and alter as needed. For assistance with a completely researched, tailored letter, call the helpline @ 920.664.9407. 
 
[Your name]
[Your address]
 
[Date]
 
[Address of your health plan’s appeal department]
 
RE:  [Name of the Insured]
Plan ID #: [123]
Claim #: [456]
 
To Whom It May Concern:
 
I’m requesting a review of your denial of [coverage, pre-authorization, or other] of the treatment 
prescribed by my medical provider [Dr___] on [date].  
 
The reason for the denial was listed as [ ____ ], but in reviewing the most current version of my plan 
summary, my provider and I believe [ ____ ] should be covered.
 
At this point in your insurance appeal letter, you should customize the message to your particular situation and include only relevant facts.  This is your opportunity to tell them a little about “what” happened, and a lot of “why” you think it should be covered.  Short factual statements are more likely to win your appeal than letters that are long and full of emotion or commentary not relevant to the issue/claim.
 
If you’re providing a lot of documents, tell them in this insurance appeal letter what is included, and in what order you’ve arranged the items. If appropriate, use a table of contents.
 
Once you’ve stated your case, let them know where you can be reached should they want additional information.  
 
I look forward to your direct response as soon as possible.
 
Sincerely,
 
[Your name]
[Contact Info]