How to request your claim file

Your claim file is everything your plan used or created when it decided your claim: the reviewer’s notes, the rule it applied, the records it looked at and the letters about it. Under the federal claims rule for job-based plans you can ask for it free of charge, and you can ask before you appeal. Ask in writing, say the letter is a records request and not an appeal, and send it so you can prove the plan received it.

What this means

Asking for the file first shows you what the plan relied on, so your appeal can answer it directly.

For a job-based plan, the federal claims rule says that on request, and free of charge, you must be given reasonable access to and copies of all documents, records and other information “relevant” to your claim. Relevant means:

• anything the plan relied on;
• anything submitted, considered or created in deciding your claim, even if the plan did not rely on it;
• anything showing the plan applied its rules the same way to similar claims; and
• for group health plans, any statement of plan policy or guidance about the treatment that was denied, for your diagnosis, whether or not the plan relied on it.

Plans that are not grandfathered, and insurers, must also let you review the claim file and present evidence. Your plan document or your state’s law can give you more than these federal minimums.

What to do

1. Find where written requests go (your step). Look on your denial notice, your member card or the plan’s website for the appeals or member records address. If you cannot find one, call the member services number on your card, ask where written requests go, and write down the date, the person’s name and any reference number.
2. Write the request. Use the claim file request letter or the claim file request builder. ProPublica, a nonprofit newsroom, also offers a free letter generator called Claim File Helper.
3. Name what you want. Ask for the reviewer’s notes and case management notes, any utilization management records (the plan’s review of whether care is needed), telephone logs and call summaries, call recordings, letters and other correspondence about the claim, the medical records the plan collected, and anything else tied to your claim number. Also ask for the internal rule or guideline the plan used, the names of any medical experts it consulted, and the diagnosis and treatment codes.
4. Say what the letter is. Write that it is a request for records, not an appeal, and that you are not giving up your right to appeal.
5. Send it so you can prove it arrived. Use certified mail with a return receipt, a fax with a confirmation page, or the plan’s portal with a screenshot that shows the date. Send copies, never originals, and keep a copy.
6. Mark day 30 on your calendar. If the file has not come, follow up in writing and say which items are missing.
7. Keep your appeal moving. The plan must give you at least 180 days after you receive the denial notice to appeal, and your plan may allow more. Check the date on your notice, which controls. If the date is close, file the appeal and say when you asked for the file.

How long the plan has to answer

The federal claims rule says you get the file “on request” but, as far as this site has verified, gives no number of days. Two other rules help:

• The health privacy rule, the Health Insurance Portability and Accountability Act (HIPAA), gives you a right to your own records from a health plan. The plan must act within 30 days, with one extension of up to 30 more days if it explains the delay in writing. It may charge only a reasonable, cost-based copying fee. For a health plan, those records include its “enrollment, payment, claims adjudication, and case or medical management record systems”.
• A separate law carries a penalty of up to $110 a day for an administrator who fails to mail required plan documents within 30 days. Only a court can award it and it is discretionary. Some sources say many courts have held it does not apply to a claim file required only by the claims regulation. We have not confirmed that from the decisions, so do not count on the penalty. See how to get your plan documents.

What the plan may say, and what to say back

“We need a subpoena or a court order.” ProPublica reported insurers that said this. The federal claims rule gives you the file on request. Ask the plan to name the rule it relies on, in writing. If you have a plan from a private employer, you can call the United States Department of Labor, Employee Benefits Security Administration, at 1-866-444-3272.

“We are treating your letter as an appeal.” Reply that your letter says it is a records request, and ask the plan to log it that way and tell you in writing if it disagrees.

The rule

On request and free of charge, a claimant must be given reasonable access to, and copies of, all documents, records and other information relevant to the claim. See section 2560.503-1(h)(2)(iii) and (j)(3) of Title 29 of the Code of Federal Regulations (CFR): 29 CFR 2560.503-1.

Watch for

• Delay while you wait. ProPublica suggests asking the plan to pause your appeal clock until it sends the file. This site found no federal rule that makes a plan agree, so keep to the date on your notice.
• Other coverage. A Medicaid managed care plan must give you the case file, including medical records and any new evidence, free of charge and far enough ahead of its decision deadline. A Medicare Advantage plan must send the case file to the independent reviewer on its own if it upholds its denial or misses its deadline, which is different from sending it to you. This site has not confirmed a claim file right for Original Medicare; see Medicare.
• Coverage with fewer federal rights. Short-term plans, fixed indemnity products and health care sharing ministries are not covered by the Affordable Care Act appeal rules. Ask anyway.

What next

• How to read your claim file: what to look for once it arrives.
• How to get your plan documents: the rulebook the plan said it applied.
• How to find the insurer’s medical policy: ask for the clinical criteria behind a medical decision.
• How to keep a call log and paper trail: record every contact with the plan.