Demand your claim file before you appeal.

What the letter asks for, and why

1. The complete claim file for the adverse benefit determination identified above.
2. All documents, records and other information relied upon in making the determination, and all documents submitted, considered or generated in the course of making it, whether or not relied upon.
3. The internal rule, guideline, protocol, clinical criterion or similar standard applied in making the determination, in full, including any coverage policy, medical policy or prior-authorization criteria referenced in the denial.
4. Identification of every medical or vocational expert whose advice was obtained in connection with the determination, whether or not the advice was relied upon.
5. The name, clinical specialty and licensure of each individual who reviewed the claim and made or recommended the determination.
6. A complete copy of the plan's claims and appeal procedures, including the deadlines, the address for appeals and any expedited or external-review process.
7. Copies of all correspondence, notes, call logs and communications concerning the claim, including between the plan and any third-party administrator, pharmacy benefit manager, utilization-review vendor or provider.
8. The complete administrative record as it currently exists for this claim, together with any additional evidence or rationale the plan intends to rely on in deciding an appeal.

Items 1 to 4 track the language of 29 CFR 2560.503-1(h)(2)(iii), (m)(8), (g)(1)(v)(A) and (h)(3)(iv). Item 5 asks the plan to identify the reviewer; the regulation requires that medical-judgment denials be reviewed in consultation with an appropriately trained and experienced health professional ((h)(3)(iii)) and that consulted experts be identified ((h)(3)(iv)). Items 6 to 8 are plan documents and the administrative record, which is what any later review is decided on.

Not through a private employer?

ERISA does not cover federal, state or local government employee plans, most church plans, or individual and marketplace coverage. Those plans are governed by state insurance law and, for non-grandfathered coverage, 45 CFR 147.136, which gives similar rights to the evidence and rationale behind a denial. Medicare and Medicaid run on their own appeal tracks. Tick the box above and the letter cites those sources instead of ERISA. If you are not sure whether your plan is an employer plan, this guide helps you tell.

Sources

• 29 CFR 2560.503-1, Claims procedure (ERISA): (g)(1)(v)(A), (h)(2)(iii), (h)(3)(iii)-(iv), (m)(8)
• 29 U.S.C. 1024(b)(4), ERISA section 104(b)(4), plan documents on written request
• 45 CFR 147.136, Internal claims and appeals and external review processes
• DOL EBSA, Filing a Claim for Your Health Benefits