The denial letter gives no real reason. What can I demand?
A written notice that states the specific reason, the plan provision relied on, the clinical criteria or guideline used (or that one will be provided free on request), what additional information would change the decision, and your appeal rights. A notice that says only "not covered" or "not medically necessary" does not meet the rules, and asking for the missing items in writing is the first move of the appeal.
What to do, in order
- Step 1
Send the disclosure request
One letter: claim number, and a request for the specific reason, the plan provision, the internal rule or clinical criteria applied, the reviewer's credentials, and the claim file. Cite the plan's claims procedure. The plan must provide them free of charge.
- Step 2
Note the timeframe
The plan should respond within the appeal decision period at the latest. A plan that decides an appeal without giving you the criteria first has not given a full and fair review, which is itself a ground of appeal and of deemed exhaustion.
- Step 3
Appeal on the record you now have
Once the criteria arrive, answer them point by point with the medical records. If they never arrive, say so in the appeal and in the external review request.
- Step 4
Escalate the notice defect
For insured plans, the state insurance department takes complaints about defective notices; for self-funded plans, the Department of Labor.
The deadline that applies
Your appeal deadline runs from the notice even if it is defective, so file within 180 days regardless (29 CFR 2560.503-1; 45 CFR 147.136). Medicare Advantage notices must also state the specific reason and the criteria (42 CFR 422.568), with 65 days to appeal.
Calculate your date →Documents to gather
- The denial notice as received
- Your disclosure request with proof of delivery
- The plan's reply, or a note of its silence
- The medical records that meet the criteria once you have them
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Related questions
Is a code like "CO-50" a reason?
It is a category. The rules require the specific reason and the provision, which is what you ask for.
Can the plan charge for the claim file?
No. Under ERISA and ACA rules the documents relevant to the claim are free on request.
What if the plan says the criteria are proprietary?
They must still be provided to a claimant on request. Put the refusal in writing and in the appeal.
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
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