How to File an Internal Appeal 

1. Understand the Denial: Read the denial letter carefully. When your claim is denied, the insurer will send a written explanation detailing the reasons for the denial. This letter is usually called a "Notice of Adverse Benefit Determination.” It should provide the reason(s) your claim was denied (e.g., "not medically necessary," "out-of-network," "experimental," etc.), any specific policy clauses or exclusions that were cited, information on how to appeal the decision, and the deadline. 

2. Identify the specific issue: Make sure you fully understand why your claim was denied. This will help you gather the right information and make a strong case. 

3. Review Your Health Insurance Policy: Review your policy to verify if the service or treatment is covered under your plan. Pay close attention to any exclusions, limitations, or conditions related to the coverage. 

4. Look at the appeals process: Most health insurance companies have detailed instructions on how to file an appeal, including timelines, forms, and what information is needed. You can often find this in your benefits manual or on the insurer’s website. 

5. Request all files related to the claim: Every insured always has the legal right to request all files generated around their claims. This can include audio recordings of insurance employees’ phone calls, internal notes and information on any cost-saving policies or programs that cases may have been funneled into. By law insurers must respond to the claim file request within 30 days. 

Claim Form Template

6. Gather Supporting Documentation: Obtain all relevant medical records and documentation from your healthcare provider that support the medical necessity of the request. This could include lab results, doctor’s notes, medical history, and test results. 

7. Letter from your doctor: Ask your healthcare provider to write a letter or provide an opinion explaining why the request is medically necessary. This can be crucial, especially if the denial is based on a lack of medical necessity.

8. Relevant research or clinical guidelines: If the insurer denied a treatment based on the "experimental" or "investigational" label, providing clinical studies or guidelines supporting the effectiveness of the treatment can help strengthen your case. 

9. Write a Letter of Appeal: Draft a letter outlining your reasons for appealing the denial. Be clear about the facts of your case and refer to the evidence you are submitting. Include key details such as your full name, contact information, insurance ID number, the specific claim or service being denied, a detailed explanation of why you believe the claim should be approved (including the “four words”), citing medical evidence, guidelines, or policy language.  

10. Submit the Appeal According to the Insurer’s Instructions: Follow the insurer’s instructions for submitting the appeal and make sure you submit it within the required timeframe. Most insurance companies give you 180 days from the date of the denial but check your plan’s policy for the exact time limits. Make sure you submit your appeal through the correct channel. Some insurers require that appeals be submitted online, while others may have a form you need to fill out or ask for a hard copy submission via mail.  

11. Keep Copies! Make sure to keep copies of everything you submit, including the appeal letter, supporting documents, and any forms. 

12. Follow Up: After submitting your appeal, confirm receipt with the insurer. If possible, get a confirmation number or email. 

13. Stay organized: Keep a log of all communications, including dates of phone calls, emails, or letters. If you are following up, reference your appeal number or claim number. 

14. Review the decision: Once the insurance company has reviewed your appeal, they are required to notify you of their decision, typically within 30 days for urgent cases or 60 days for non-urgent cases. Some insurers may take longer, but they should inform you if there will be any delays. 

15. Be ready to escalate: If the appeal is denied again, you may have the option of filing an external appeal. Your insurer is required to provide information on how to do this. 

By carefully following these steps, you will increase your chances of a successful internal appeal. 

The ALS insurance Navigator™ is brought to you by Biogen and other supporters:

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