How do I request my claim file from my insurer?
Send a short written request for all documents, records and information relevant to the claim, the internal rules or criteria the plan relied on, and the identity and qualifications of the reviewers; on employer and ACA plans the plan must provide them free of charge. Apellica's free generator writes the letter with the regulatory citations for you.
What to do, in order
- Step 1
Write the request to the address on the denial letter
Name the claim number, the date of the denial, and ask for the full claim file, the criteria relied on, and the reviewer's identity and specialty.
- Step 2
Cite the rule
29 CFR 2560.503-1(h)(2)(iii) and (m)(8) for employer plans; 45 CFR 147.136(b)(2)(ii)(C) for individual and non-grandfathered plans. Citing it changes how the request is handled.
- Step 3
Send it in a way you can prove
Fax with confirmation, certified mail, or the portal's message centre with a screenshot.
- Step 4
Use what comes back
The criteria tell you what the appeal must prove. A missing or late file is itself an argument for full and fair review.
The deadline that applies
A claim-file request has no deadline of its own, but it does not pause your appeal clock: file the appeal on time even if the file has not arrived, and supplement when it does.
Calculate your date →Documents to gather
- The denial letter (claim number, date)
- Your member ID
- A one-page request letter
Go deeper
Related questions
Can the plan charge me for the file?
Not on employer or ACA-compliant plans: the rule says free of charge.
What if they send only the denial letter again?
Reply that the request covers all documents relevant to the claim as defined in 29 CFR 2560.503-1(m)(8), including internal criteria and reviewer notes, and note the date of your original request.
Does this work for Medicare Advantage?
MA has its own access rules; you can request the case file from the plan and, on appeal, from the Independent Review Entity. The wording differs but the request is still worth making.
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.
Start a free denial review →