The plan must show you the rule it used
A denial has to name the specific plan provision, internal rule or guideline it relied on, and the plan must give you that rule and the whole claim file free of charge when you ask. A denial that cannot produce its criteria is procedurally defective, which is a ground of appeal in itself.
When it applies
- Employer plans (insured or self-funded) under ERISA
- Individual and marketplace plans under the ACA rules, which adopt the same disclosure duties
- Any denial letter that cites 'our guidelines' or 'medical policy' without attaching or naming them
Where it does not
- Original Medicare and Medicaid have their own disclosure rules (the case file is still obtainable, under different citations)
- Church and some government plans outside ERISA
The sentence to put in the appeal
“Under 29 CFR 2560.503-1(g)(1)(v) and (h)(2)(iii), I request the specific internal rule, guideline, protocol or criterion relied upon in denying claim [number], and all documents, records and other information relevant to the claim as defined in section (m)(8), free of charge. The denial notice does not identify the criterion applied; absent it, the determination does not satisfy the full and fair review requirement.”
Replace the bracketed parts with your facts. Cite the regulation exactly as written; quote the plan’s own wording next to it.
How to use it
- Step 1
Send the request in writing before or with the appeal
Cite the regulation, name the claim, and ask for the criteria, the reviewer's identity and qualifications, and every document considered. Keep proof of delivery.
- Step 2
Answer the criteria point by point
When the criteria arrive, the appeal walks through each element with the record. When they do not arrive, the appeal says so and asks the reviewer to note the omission.
- Step 3
Use the omission at external review
The external reviewer sees a plan that did not identify its basis. That framing is procedural, not medical, and does not depend on the clinical argument.
Worked example
A biologic infusion was denied as 'not meeting clinical policy'. The claim-file request produced the policy, which required one failed conventional therapy; the record showed two. The appeal quoted the policy's own wording next to the dates in the chart.
Illustrative composite; details vary by plan and record. Outcomes are not guaranteed.
Go deeper
Sources
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