Once you have the information you need for your appeal, the next step is putting together an argument. Whether you are writing your first level appeal or presenting your second and external appeals over the phone or in person, your arguments should be organized like this:
Introduction
- Start with a statement of what you want.
- Explain that you are appealing the insurance company’s decision not to cover the service or item you need.
- Note the date on the denial notice you received.
- Say briefly why you think the insurance company should cover the service or item you need.
- Tell the facts that are important to your situation. It is usually best to tell the facts in the order that they happened.
Argument
- Say why the service or item should be covered and why the insurance company is wrong not to cover it.
- Show parts of the member handbook, contract or other language that support your argument.
- Give copies of letters of support from your physician(s) and talk about the letters in your argument.
Be sure to address the reasons the insurance company gave in its denial notice for refusing to cover the service.
Conclusion
- Briefly say what you want the insurance company to do and why.
For more information about private insurance plan appeals, visit this Department of Financial Regulation web page about how to appeal a denial of benefits.