Health Coverage Denial and Appeal Checklist: A Practical Checklist

Summary. A deadline-driven checklist: the day-one questions, the claim file, reading the criteria, the medical necessity letter, the internal appeal, external review, regulatory complaints, the bill, and the record rule.

For doctrine, see Health Insurance Denials and Appeals. For the workflow, see Appealing a Health Insurance Denial.

⚠ On a self-funded ERISA plan, the internal appeal is your ONLY chance to build a record. A court will generally review only what the plan had.

Phase 1 — Day one

The specific reason identified from the letter (not medically necessary · experimental · not a covered benefit · out of network · no prior authorization · not eligible · exceeds limits).
The internal appeal deadline found and calendared (generally 180 days).
The external review deadline noted (generally ~4 months from the final internal denial).
"Is our plan self-funded or fully insured?" asked of HR in writing, or the Summary Plan Description checked.
If urgent: expedited appeal requested the same day (72-hour decision; runs concurrently with expedited external review).
Provider notified in writing that an appeal is pending.

Phase 2 — The claim file request (free, and almost nobody does it)

Request, under 29 C.F.R. § 2560.503-1, free of charge:

The complete claim file.
All internal rules, guidelines, protocols, and medical necessity criteria relied on.
The identity, credentials, board certification, and specialty of every reviewer, and whether each is an employee, contractor, or consultant.
Any medical or vocational expert advice obtained, whether or not relied upon.
The specific plan provisions relied on.
The Summary Plan Description and the plan document.
All notes, correspondence, and system entries.
Extension of the appeal deadline requested for the time taken to produce them.

Phase 3 — Read the criteria against the record

Criteria printed; records printed.
Each criterion marked: met? and WHERE — document, date, page.
Reviewer's specialty checked against the condition. (Specialty mismatch is a substantive point; many states require matching.)
Plan language read: does the exclusion actually cover this service? Does another provision cover it?
Denial correctly characterized — clinical (external review available) vs. contractual/eligibility (generally not).

Phase 4 — The letter of medical necessity

Physician given the denial letter and the criteria.
Letter addresses each stated ground by quoting it, then answering it.
For each criterion: the plan's language · the clinical finding · where in the record, by date.
Treatment history: what was tried, how long, at what dose, why it failed or was contraindicated. (Defeats step therapy and "less intensive alternative" rationales.)
Consequence of denial stated clinically and specifically.
Literature cited, with the relevant conclusion stated.
Reviewer's stated reasoning answered directly.
Peer-to-peer review requested (resolves many denials in twenty minutes).

Phase 5 — File the internal appeal

In writing. (A phone call is not an appeal.)
Structure: identification · what you want, in one sentence · each ground answered · plan language quoted · enclosures listed.
Preservation language included: "I request that all enclosed materials be included in the administrative record."
Enclosed: physician letter · records with entries flagged · literature · authorization numbers · anything you might ever want a judge to see.
Specialty review requested where the reviewer was mismatched.
New-rationale protection requested: any new evidence or rationale developed during review to be provided free of charge and sufficiently in advance, with an opportunity to respond.
Sent traceably; proof of delivery kept.
Plan's decision deadlines diaried: 72 hours (urgent) · 30 days (pre-service) · 60 days (post-service).
If the plan misses a deadline → treat as denied and proceed; note the procedural failure.

Phase 6 — External review (the step most often skipped)

Filed within ~4 months of the final internal denial.
Correct process identified: state (fully insured/individual) or federal (self-funded ERISA not subject to a state process).
Everything from the internal appeal resubmitted, plus anything new (this is a fresh clinical look).
Expedited external review requested where urgent (runs concurrently with expedited internal appeal).
Understood: the decision binds the plan, the reviewer is independent, and it is free.

Phase 7 — Regulatory complaints (in parallel, all free)

State Department of Insurance (insured/individual) — complaint volumes are tracked and used in market conduct exams.
U.S. Department of Labor, EBSA (ERISA plans) — benefits advisors contact the plan.
CMS / federal No Surprises Act complaint, for prohibited balance billing.
State attorney general consumer protection, where there is a pattern.
Parity comparative analysis requested in any mental health or substance use denial — plans must maintain and produce it.

Phase 8 — Denial-specific moves

Prescription drug: formulary exception · step therapy exception (prior failure, contraindication, expected ineffectiveness) · quantity limit exception.
Emergency care denied on the final diagnosis: quote the prudent layperson standard; attach the triage note. Reasoning backward from the discharge diagnosis is unlawful.
Out of network: was the provider in network on the date · is there a network adequacy exception (no in-network provider with the expertise) · do No Surprises Act protections apply?
Experimental/investigational: FDA status · compendium listing · peer-reviewed evidence · the plan's own definition.
No prior authorization: request retrospective authorization; check emergent status, provider misinformation, and directory errors.
DME/home health: detailed written order plus a face-to-face note tying the equipment to a specific functional limitation.
Retroactive denial after authorization: raise the authorization, recorded confirmations, and state prompt-payment and prior-authorization statutes.

Phase 9 — The bill, while appealing

Provider notified in writing; account held rather than sent to collections.
Hospital financial assistance policy requested (nonprofit hospitals must maintain and publicize one; thresholds are higher than most assume).
Itemized bill requested and audited: duplicates · services not rendered · wrong codes · items included in a facility fee.
No balance bill paid in a No Surprises Act-protected situation.
EOB compared to the provider bill — never pay more than the patient responsibility on the EOB.
Credit protected: medical debt reporting restrictions known; any reported disputed bill disputed under the FCRA.
Treatment continued — a gap harms the patient and undermines the necessity argument.

Phase 10 — If it goes to court (ERISA)

Action under 29 U.S.C. § 1132(a)(1)(B).
Record understood to be closed — everything had to be submitted during the internal appeal.
Standard of review determined: discretionary clause present? Does the state ban discretionary clauses in insurance policies? (Firestone)
Arguments preserved: paper reviewer disregarding treating physicians without explanation (Nord) · structural conflict where the decider pays (Glenn) · criteria not in the plan document · failure to follow the claims procedure · rationale first raised in the final letter.
Remedies understood: benefits, interest, and attorney's fees only (§ 1132(g); Hardt). No damages, no jury, state bad faith preempted.
Fee shifting noted — representation is available on contingency in strong cases.

Phase 11 — Coverage disputes (not clinical)

Rescission: permitted only for fraud or intentional misrepresentation of material fact, with 30 days' notice — and it is subject to external review.
COBRA: election notice received? 60 days to elect, 45 days to pay, coverage retroactive.
Special enrollment period: 60 days after loss of coverage, marriage, birth, or move. Compare subsidized marketplace coverage against COBRA before electing.
Nonpayment termination: grace period identified (three months for marketplace enrollees with APTC; often 30 days otherwise).
Eligibility and coordination of benefits disputes treated as adverse benefit determinations, appealed in writing.

Phase 12 — Prevention, going forward

Coverage verified in writing before planned services; reference numbers recorded.
Prior authorization confirmed personally, with the authorization number, expiration, and unit limit.
Network status verified for every provider — facility, surgeon, anesthesiologist, pathologist, radiologist, assistant.
CPT and diagnosis codes obtained from the provider and used when verifying.
At open enrollment: formulary checked for your actual drugs; network checked for your actual providers, by name, and confirmed by phone; total exposure modeled, not just premium.
EOB file maintained and reconciled against every bill.
Someone other than the patient assigned to run the paperwork.