How to read your claim file

Read the file twice. The first time, check that everything you asked for is there. The second time, read it as the plan’s reviewer would, and write down what the plan relied on, what it did not have, and where its own papers disagree. That list becomes the outline of your appeal.

What this means

A claim file is a set of papers: the plan’s notes, the rule it applied, the records it collected, any recordings or call logs, and its letters. It does not explain itself. Some of it is written in the plan’s shorthand. You are not trying to understand every line. You are looking for five things: the reason, the rule, the reviewer, the records and the dates.

If you have not asked for the file yet, start with how to request your claim file.

What to do

1. Check it is complete (your step). Lay out your request letter beside the file. Tick off each item you asked for: reviewer notes, case management notes, call logs and recordings, the rule or guideline, correspondence, medical records. Write to the plan about each missing item and ask it to confirm in writing that nothing else exists. Keep the proof of delivery.
2. Make a timeline. Write down the date each document was received, reviewed and decided. Compare it with the plan’s deadlines for a first decision: no later than 72 hours for an urgent claim, 15 days for a claim that needs approval before care, and 30 days for a claim for care you already had. A plan may extend the 15-day and 30-day periods once, by up to 15 days, for matters beyond its control, if it tells you before the first period ends. If the plan missed a date, see when the plan misses its deadline.
3. Find the reason in the reviewer’s own words. The denial notice must state the specific reason and the plan provisions relied on. Compare the notice with the reviewer’s notes. If the notes give a different reason, or a more specific one, quote both in your appeal and answer both.
4. Find the rule the plan applied. Look for an internal rule, guideline or protocol, and for the clinical explanation if the denial rests on medical necessity or on a finding that the care is experimental. Note its title, version and date. If it is not in the file, ask for it with the clinical criteria request letter.
5. Check who reviewed the claim. Look for the reviewer’s name and field. A medical necessity denial on appeal must go to a health care professional with training and experience in the field, who was not consulted on the first decision. The plan’s procedures must also provide for identifying medical experts it consulted, even if it did not rely on them. If names are missing, use the reviewer identity request letter.
6. Find the gaps. Write down every record the reviewer did not have: a test, a specialist’s note, a record of treatments you tried. Also note facts the file gets wrong, such as dates, a diagnosis or a service. Anything missing can be sent with your appeal, and the plan must consider all of it, including material the first reviewer never saw.
7. Hand the rule to your doctor (your doctor’s step). Ask your doctor to go through each requirement in the plan’s rule and mark what your records show. See how to ask your doctor for a letter.
8. Write your list. Make three columns: what the plan says, what your records show, and what you will send. Use it to write the appeal.

What to look for, in short

In the file	Why it matters	What you do
The reason in the notes	It may be narrower or different from the notice	Answer the reason in the notes as well as the notice
The rule or guideline	It is the standard you must meet	Match each requirement to a record
The reviewer	Training in the right field is required on appeal	Ask for the name and field if missing
The records reviewed	The plan cannot weigh what it never saw	Send the missing records
The dates	They show whether deadlines were met	Write the dates into your letter

What the plan may say, and what to say back

“This is the complete file.” Ask the plan to confirm in writing which categories it searched. If your list shows a gap, such as no call logs or no reviewer notes, name it.

“The reviewer’s notes are not part of the file.” Anything submitted, considered or created in deciding your claim is relevant under the claims rule, even if the plan did not rely on it. Ask again, in writing, for the notes.

The rule

The documents you can ask for include anything the plan relied on, anything submitted, considered or created in deciding the claim, and, for group health plans, any statement of plan policy or guidance about the denied treatment for your diagnosis. See the definition of “relevant” in section 2560.503-1(m)(8) of Title 29 of the Code of Federal Regulations (CFR): 29 CFR 2560.503-1.

Watch for

• New evidence late in the process. Before a plan that is not grandfathered issues a final internal denial, it must give you, free of charge, any new or additional evidence it considered or created, and any new reason, early enough for you to respond. If something new appears in a later letter, write back at once.
• Medicare Advantage. A Medicare Advantage plan must follow Original Medicare’s coverage rules, including its national and local coverage determinations. It may write its own criteria only where Medicare’s are not fully established, and it must post them. Before it denies on medical necessity, a physician or other appropriate health care professional with expertise in the field must review the request. Check the file for the reviewer’s field, and ask which rule the plan applied and where it is posted.
• Reading the file is not medical advice. If a rule in the file looks wrong for your condition, take it to your doctor. Do not decide medical questions yourself.
• Your deadline did not pause. 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.

What next

• How to find the insurer’s medical policy: get the clinical criteria if the file lacks them.
• Using your plan’s own words: turn what you found into quotations for your appeal.
• How to write an appeal letter that works: put your list into a letter.
• How to file an internal appeal: where to send it and when the plan must answer.