Appeal: emergency care denied
Asks your plan to cover an emergency visit using the prudent layperson standard, judged on your symptoms at the time rather than the final diagnosis.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this when your plan denied an emergency room visit as not an emergency, or applied out-of-network or approval rules to it. If your bill is for a ground ambulance, the federal surprise-billing protections do not cover it, so this letter may not fit.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the plan's appeals department]
Re: Appeal: emergency care denied Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am appealing the decision dated [Date on the denial notice] on claim [Claim or reference number], which denied or reduced payment for emergency care I received at [Doctor, hospital or pharmacy] on [Date of the care]. The plan's reason was: [The reason the plan gave] I ask you to reverse that decision and process this claim as emergency services under [Name of the health plan], member ID [Member ID].
Before I went, I was experiencing: [What you were feeling that made you seek care] I got to the emergency room this way: [How you got to the emergency room]. The hospital later told me the cause was: [What the hospital told you was wrong]
Whether a visit is an emergency is judged on the symptoms at the time, not on the final diagnosis. The federal rule asks whether "a prudent layperson, who possesses an average knowledge of health and medicine" could reasonably expect that going without immediate care would seriously jeopardize health, seriously impair bodily functions, or cause serious dysfunction of an organ, based on symptoms including severe pain. A plan may not decide that a visit was not an emergency solely on the basis of diagnosis codes. My symptoms met that standard.
If a plan covers emergency department services at all, it must cover emergency services without prior authorization, whether or not the provider is in network, with cost sharing no greater than in-network cost sharing, counted toward my in-network deductible and out-of-pocket maximum. I ask you to reprocess the claim on that basis.
Under the federal claims and appeals rules, including Title 29 of the Code of Federal Regulations (CFR), sections 2560.503-1 and 2590.715-2719 (for individual coverage, 45 CFR 147.136), I ask that someone who was not involved in the first decision decide this appeal, give no deference to it, and consider every record and comment I send.
Please send me your decision in writing within the time the rules allow. If you uphold the denial, I will ask for external review and may file a complaint with the agency that regulates my plan.
Enclosures: 1. Copy of the denial letter and Explanation of Benefits 2. Emergency room visit notes and discharge papers 3. The ambulance bill or record, if any
Sincerely, [Your name]
Before you send it
Send it to the appeals address printed on your denial notice, by a method that proves delivery, such as certified mail with a return receipt or the plan's online portal with a saved confirmation page. Keep a complete copy of the letter and everything you enclose, and write down the date and the method you used.
What to enclose
- Copy of the denial letter and Explanation of Benefits
- Emergency room visit notes and discharge papers
- The ambulance bill or record, if any
What happens next
- Your plan must decide within 60 days after it receives your appeal, because the care has already happened. If your plan has two appeal levels, each level gets 30 days. Check the date on your notice, which controls.
- Ask the hospital's billing office in writing to hold the bill while you appeal; they are not required to agree, and an unpaid bill can go to collections, so ask before you withhold any payment. Before you pay a balance bill, check whether the surprise-billing protections apply (ground ambulance is not covered). Where they apply, you may owe only in-network cost sharing.
- If the plan says no again, ask for external review. A denial that turns on whether surprise-billing protections apply, or on a medical judgment, can go to external review, including for plans that are grandfathered. For most job-based and individual plans you have at least four months after you receive the final denial; other coverage can differ. Check the date on your notice, which controls.
- You can also file a complaint about a surprise bill with the No Surprises Help Desk at 1-800-985-3059.
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".
The rule behind this
Sources
Denial reasons this answers
- Denial reason
Not an emergency
Your plan says your emergency room visit was not a true emergency, so it denied the claim or paid it at a lower rate. The test is what your symptoms looked like to an ordinary person, not the final diagnosis.