Health Insurance Appeal Toolkit: Internal Appeals, External Review, and ERISA Litigation

Summary. A working kit: the plan type diagnostic, the document requests, the criteria worksheet and response map, the letters that decide appeals, external review and complaints, specialty requests, and the ERISA litigation instruments.

SECTION A — THE PLAN TYPE DIAGNOSTIC

Ask HR, in writing: "Is our health plan self-funded or fully insured?" Then read across.

Everything else in this toolkit depends on this table. On a self-funded plan, the internal appeal is the only chance to build a record.

SECTION B — DOCUMENT REQUESTS

B-1. Claim file request (send day one)

Re: Member [name], ID [] · Claim [] · Denial dated [__] — Request for documents under 29 C.F.R. § 2560.503-1

I am appealing the above adverse benefit determination. Pursuant to the claims procedure regulation, I request, free of charge, all documents, records, and other information relevant to the claim, specifically:

1. The complete claim file.
2. All internal rules, guidelines, protocols, and medical necessity criteria relied upon, including the version in effect on the date of service.
3. The identity, professional credentials, board certification, and specialty of every individual who reviewed the claim, and whether each is an employee, contractor, or consultant of the plan or administrator.
4. Any medical or vocational expert advice obtained in connection with the claim, whether or not relied upon.
5. The specific plan provisions on which the denial is based.
6. The Summary Plan Description and the governing plan document, including any amendment conferring discretionary authority.
7. All notes, correspondence, call records, and system entries concerning the claim.
8. Confirmation of whether the plan is self-funded or fully insured.

Please provide these within 30 days. My appeal deadline is [date]; I request that it be extended by the time taken to produce these documents.

B-2. Records and coverage requests

□ PROVIDER: complete medical records for the relevant period,
  plus the CPT and diagnosis codes submitted
□ PROVIDER: the prior authorization request and any authorization
  number, expiration, and unit limit
□ PLAN: the certificate of coverage / evidence of coverage
□ PLAN: the formulary in effect on the date of service
□ PLAN: the provider directory entry for each provider involved,
  as of the date of service
□ EMPLOYER: Summary Plan Description; Form 5500 (public) to
  confirm funding status
□ FACILITY: itemized bill; financial assistance policy and
  application
□ PLAN (mental health/SUD): the PARITY COMPARATIVE ANALYSIS of
  non-quantitative treatment limitations

SECTION C — ANALYSIS WORKSHEETS

C-1. Criteria comparison — where most denials fail

Also record:

• Criteria set used and its version: ______________________
• Was the version in effect on the date of service? ☐
• Reviewer name and specialty: ____________________
• Does the reviewer's specialty match the condition? ☐ Yes ☐ No → request specialty review
• Was the reviewer an employee of the entity that pays claims? ☐ (→ Glenn conflict factor)
• Did the reviewer examine the patient? ☐ (→ Nord — no arbitrary refusal to credit reliable evidence)

C-2. Denial type → response map

SECTION D — THE LETTERS

D-1. Letter of medical necessity — physician template

[Letterhead] · [Date]

Re: [Patient], DOB [], Member ID [] · Denial dated [__] of [service]

I am [Patient]'s treating [specialty] and have cared for [him/her/them] since [date]. I write in response to the denial dated [__], which stated: "[quote the reason exactly]." I address each stated ground below.

Ground 1: "[quote]." The plan's criteria require [quote the criterion]. [Patient] meets this: [clinical finding], documented in [record, date, page].

Ground 2: "[quote]." [Same structure.]

Treatment history. [Patient] has been treated with:

Treatment	Dates	Dose/duration	Outcome
			Failed / not tolerated / contraindicated

Less intensive alternatives have been exhausted for the reasons stated.

Clinical consequence of denial. Without [service], [Patient] is at risk of [specific outcome], for these reasons: [__].

Supporting literature. [Citation] — [the relevant conclusion, one sentence]. [Repeat.]

Response to the reviewer. The determination states [reviewer's reasoning]. I respectfully disagree because [specific clinical response].

I am available for a peer-to-peer discussion at [direct number].

[Signature · credentials · NPI]

D-2. Peer-to-peer request

Re: [Patient], Member ID [] · Claim [] · Denial dated [__]

I request a peer-to-peer review with the reviewing physician regarding this determination. Please have the reviewer contact me at [direct number]; I am available [times].

I request that the reviewer be board-certified in [specialty], the specialty in which this condition is treated.

Please confirm the reviewer's name and specialty in advance, and confirm that this request does not extend or toll the appeal deadline of [date].

D-3. Internal appeal letter

Re: APPEAL OF ADVERSE BENEFIT DETERMINATION Member [name] · ID [] · Claim [] · Date of service [] · Denial dated []

I appeal the denial of [service]. It should be reversed because [one sentence].

1. The determination. On [date] the plan denied [service] on the ground that "[quote]," citing [plan provision].

2. The plan's own criteria are satisfied. The criteria produced in response to my request of [date] require: (a) []; (b) []; (c) [__].

Criterion	Met	Record citation
(a)	Yes	[document, date, page]
(b)	Yes	[document, date, page]
(c)	Yes	[document, date, page]

3. Treatment history. [What was tried, how long, at what dose, why it failed or was contraindicated.]

4. Reviewer qualifications. The determination was made by [name], board-certified in [specialty]. This condition is treated by [specialty]. I request review by a physician in the appropriate specialty.

5. Plan language. Section [] provides "[quote]." The exclusion relied upon, Section [], addresses [__], which is not this service.

6. Enclosures — I request that ALL of the following be included in the administrative record: · Letter of medical necessity of Dr. [], dated [] · Medical records [dates], with supporting entries flagged · [Literature] · [Authorization records] · [Prior EOBs]

7. Requests. (a) That the denial be reversed and the claim paid; (b) That the appeal be reviewed by a physician board-certified in [specialty]; (c) That any new or additional evidence or rationale developed during this review be provided to me free of charge and sufficiently in advance of the decision, with a reasonable opportunity to respond, as the claims regulation requires; (d) That I be advised of my external review rights with the determination.

[Name · date · sent by certified mail / fax confirmation / portal receipt]

D-4. Expedited appeal request

URGENT — EXPEDITED APPEAL REQUESTED

Re: [Patient] · Member ID [] · Claim [] · Denial dated [__]

I request an expedited review of this determination. The standard timeframe would seriously jeopardize [the patient's life / health / ability to regain maximum function], because: [specific clinical facts — the treatment window, the deterioration expected, the physician's statement].

Dr. [__] has certified this urgency in the attached letter and is available at [number].

A determination is required within 72 hours. I simultaneously request expedited external review, to run concurrently.

Please confirm receipt immediately at [number/email].

SECTION E — EXTERNAL REVIEW AND COMPLAINTS

E-1. External review request

Re: REQUEST FOR EXTERNAL REVIEW Member [name] · ID [] · Claim [] · Final internal denial dated [__]

I have exhausted the plan's internal appeal process and request external review by an Independent Review Organization.

The determination involves medical judgment: the plan denied [service] as [not medically necessary / experimental or investigational / not appropriate at this level of care], which is within the scope of external review.

Enclosed: the initial denial · the final internal denial · the complete internal appeal with all enclosures · the letter of medical necessity · the medical records · the supporting literature · [any new evidence].

[Where applicable:] I request expedited external review because the standard timeframe would seriously jeopardize [health / ability to regain maximum function]. A physician certification is enclosed.

Plan type: ☐ Fully insured (state process) ☐ Self-funded ERISA (federal process)

E-2. Regulatory complaints

□ STATE DEPARTMENT OF INSURANCE  (fully insured / individual)
   Include: policy number · denial letters · appeal correspondence ·
   a one-page chronology · what you want.
   Why it works: complaint volumes are tracked, reported, and used
   in market conduct examinations.

□ U.S. DOL — EMPLOYEE BENEFITS SECURITY ADMINISTRATION  (ERISA)
   Benefits advisors contact the plan; effective on PROCEDURAL
   failures — missed deadlines, refusal to produce the claim file,
   denial letters lacking specific reasons.

□ CMS / FEDERAL NO SURPRISES ACT COMPLAINT
   For prohibited balance billing.

□ STATE ATTORNEY GENERAL — consumer protection, for patterns.

□ STATE INSURANCE COMMISSIONER — MARKET CONDUCT
   For systemic issues, including PARITY.

SECTION F — SPECIALTY REQUESTS

F-1. Formulary exception

I request a formulary exception for [drug], prescribed for [condition].

Formulary alternatives tried and their outcomes:

Drug	Dates	Dose	Outcome
			Ineffective / adverse reaction / contraindicated

[Where no alternative has been tried:] All formulary alternatives are expected to be ineffective or to cause an adverse reaction for the following clinical reasons: [__].

The prescriber's supporting statement is enclosed. Please advise of the determination within the statutory timeframe, and of my right to expedited review if the standard timeframe would jeopardize health.

F-2. Step therapy exception

I request an exception to the step therapy protocol for [drug], on the following ground(s): ☐ The required drug was already tried and was ineffective or caused an adverse reaction. [Dates, dose, outcome, records enclosed.] ☐ The required drug is contraindicated or is expected to cause an adverse reaction. [Clinical basis.] ☐ The required drug is expected to be ineffective based on the patient's clinical characteristics. [Basis.] ☐ The patient is stable on the current drug under a previous plan or prior authorization, and a change presents a risk of destabilization.

[Most states mandate an exceptions process with a short turnaround — cite it.]

F-3. Emergency denial — prudent layperson appeal

The plan denied coverage for emergency services on the ground that the final diagnosis was [__]. That is not the standard.

Coverage of emergency services turns on whether a prudent layperson with an average knowledge of health and medicine would have believed that the absence of immediate medical attention could reasonably be expected to place the person's health in serious jeopardy — judged on the presenting symptoms, not on the eventual diagnosis.

[Patient] presented with [symptoms], as documented in the enclosed triage note of [date, time]. A prudent layperson experiencing [symptoms] would reasonably believe emergency care was required.

A determination reasoning backward from the discharge diagnosis is contrary to law. I request that the denial be reversed and the claim processed at in-network cost sharing.

F-4. Parity comparative analysis request

Re: Mental Health Parity and Addiction Equity Act — request for comparative analysis

The plan denied [service] for [mental health / substance use disorder] treatment. I request the plan's comparative analysis of the non-quantitative treatment limitations applied, including:

1. The factors and evidentiary standards used to design and apply the NQTL to MH/SUD benefits;
2. The factors and evidentiary standards used for medical/surgical benefits in the same classification;
3. A comparison demonstrating that the processes, strategies, and standards are comparable and applied no more stringently to MH/SUD benefits;
4. The specific NQTLs at issue: prior authorization · concurrent review frequency · medical necessity criteria · network admission standards and reimbursement rates.

Plans are required to perform this analysis and to make it available on request.

F-5. No Surprises Act dispute

I received a balance bill of $[__] from [provider] for services on [date]. I believe these charges are prohibited because: ☐ emergency services ☐ non-emergency services by an out-of-network provider at an in-network facility ☐ air ambulance.

Under the No Surprises Act I am responsible only for in-network cost sharing, and any remaining dispute is between the provider and the plan through the independent dispute resolution process, in which I am not a participant. I did not give valid written consent to waive these protections. [Or: the notice-and-consent process may not lawfully be used for these services.]

Please correct the bill and confirm in writing. A copy of this letter is being sent to the plan and to the federal No Surprises Help Desk.

F-6. Hospital financial assistance request

I request an application for financial assistance under [hospital]'s financial assistance policy for the account(s) listed above, and a hold on collection activity while the application is pending.

Please provide the policy, the plain language summary, the application, and the eligibility criteria, and confirm the amounts generally billed limitation applicable to my account.

Household size: [] · Household income: $[] · Documentation enclosed: [__].

SECTION G — ERISA LITIGATION

G-1. Record preservation checklist — before the record closes

EVERYTHING BELOW MUST BE IN BEFORE THE FINAL INTERNAL DENIAL.
A court will generally review ONLY what the administrator had.

□ Every medical record supporting necessity, with entries flagged
□ Letter of medical necessity addressing EACH stated ground
□ Any second opinion or consulting specialist opinion
□ Peer-reviewed literature, with the relevant conclusions stated
□ Functional evidence (FCE, activity log, work records)
□ Statements from family, employer, or caregivers
□ Prior authorizations, reference numbers, and call log
□ The plan's criteria and the reviewer credentials you obtained
□ Your written objection to any new rationale raised late
□ A cover statement: "I request that all enclosed materials be
  included in the administrative record."

G-2. ERISA complaint outline

COMPLAINT — 29 U.S.C. § 1132(a)(1)(B)

I.   PARTIES · JURISDICTION (§ 1132(e)) · VENUE (§ 1132(e)(2))
II.  THE PLAN
       Self-funded or insured · plan documents · discretionary
       clause (quote it) · whether the state bans discretionary
       clauses in insurance policies
III. THE CLAIM AND THE DENIALS, chronologically with exhibits
IV.  EXHAUSTION — every internal level completed, with dates
       [or: deemed exhausted for failure to follow the claims
       procedure, 29 C.F.R. § 2560.503-1(l)]
V.   STANDARD OF REVIEW
       De novo unless discretion is conferred (Firestone, 489 U.S.
       101). Structural conflict weighed as a factor (Glenn, 554
       U.S. 105).
VI.  COUNT I — Benefits due under § 1132(a)(1)(B)
       · The plan's own criteria were met
       · Reliance on a non-examining reviewer while arbitrarily
         refusing to credit treating physicians (Nord, 538 U.S. 822)
       · Criteria applied that appear nowhere in the plan document
       · Failure to address contrary evidence
       · Procedural violations: deadlines missed · claim file
         withheld · rationale first raised in the final denial
VII. COUNT II — Clarification of rights to future benefits
VIII.PRAYER
       Benefits · prejudgment interest · ATTORNEY'S FEES AND COSTS
       under § 1132(g) (Hardt, 560 U.S. 242 — "some degree of
       success on the merits") · declaratory relief

⚠ NOT AVAILABLE: compensatory damages · punitive damages · jury.
  State bad faith claims are preempted.

G-3. Call log

Insurers' own notes are discoverable and frequently contradict what claimants were told — but only if you can identify the call.

SECTION H — PRIMARY AUTHORITY

• 29 U.S.C. § 1132 — ERISA civil enforcement and attorney's fees.
• 29 U.S.C. § 1133 — specific reasons and a full and fair review.
• 42 U.S.C. § 300gg-19 — ACA internal appeals and external review.
• Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989).
• Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003).
• Metropolitan Life Insurance Co. v. Glenn, 554 U.S. 105 (2008).
• Hardt v. Reliance Standard Life Insurance Co., 560 U.S. 242 (2010).
• 29 C.F.R. § 2560.503-1; the Mental Health Parity and Addiction Equity Act; the No Surprises Act; state insurance codes, external review statutes, prompt payment statutes, and discretionary clause bans.

Related documents

• Health Insurance Denials and Appeals
• Appealing a Health Insurance Denial
• Health Coverage Denial and Appeal Checklist
• Veterans Benefits Toolkit
• Elder Law Toolkit
• Consumer Debt Defense Toolkit
• Fee Shifting and Litigation Cost Recovery Toolkit

This toolkit is educational and not legal advice. Whether ERISA or state law governs changes nearly every answer; adapt every letter to your plan type and jurisdiction, and verify deadlines against your own denial letter.