Certification of urgency (for your clinician)
A short letter in a physician's voice stating that the standard time frame could seriously harm the patient, so the plan must treat the claim or appeal as urgent and decide within 72 hours. Every clinical statement is a blank for the physician to complete.
- Private: nothing leaves this tab
- 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. How to hand this to the office: print it or save it with the blanks showing, clip your denial letter to it, and ask the clinician to fill in every clinical blank from your chart, edit it in their own words, and sign it. You fill in only the plan details. The wording is a starting point for the clinician, who decides what is accurate for you. Use it with a request for a fast decision. Under the federal claims rule, if a physician who knows the patient's condition says a claim is urgent, the plan must treat it as urgent. Only the physician can decide whether this is true for you. Do not use it unless it is.
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 medical reviewer]
Re: Certification of urgency (for your clinician) Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am [The clinician's name], [The clinician's credentials], a physician treating [The patient's full name], member ID [Member ID]. I know this patient's condition: [The patient's condition, briefly]
I am writing about [Name of the health plan]'s decision of [Date on the denial notice], claim or reference [Claim or reference number], concerning [The care or drug that was denied].
In my professional opinion, applying the standard time frame to this matter [Which statement applies]. My reasons are: [The clinical reasons]
I therefore ask the plan to treat this matter as a claim involving urgent care. Under the federal claims rule, a claim is urgent if a physician with knowledge of the patient's condition says so, and a plan that is not grandfathered must defer to the attending provider's determination. An urgent claim or appeal must be decided as soon as possible and no later than 72 hours.
I ask to act as the patient's authorized representative for this urgent matter. I understand that an urgent appeal may be made orally or in writing. Please give your decision to me by telephone at [A phone number where the reviewer can reach the clinician] or by fax or email at [A fax number or email for a fast reply], and send written notice as well. If you cannot decide within 72 hours, please tell me today what you need.
Enclosures: 1. Copy of the denial letter 2. Chart notes that support the statement above
Sincerely, [Your name]
Before you send it
The clinician's office should phone or fax it to the plan at once, using the appeals phone and fax numbers on the denial notice; do not guess them. Urgent matters move by phone, fax or a similarly fast method. To prove it arrived, keep the fax confirmation page, and write down the date, time, name of the person and any reference number for each call. Follow up with a copy by the fastest written method the plan accepts.
What to enclose
- Copy of the denial letter
- Chart notes that support the statement above
What happens next
- Your clinician: signs and sends the certification the same day, and phones the plan to say it is on its way.
- You: file or confirm your appeal at once, in writing, and say the physician has certified urgency. Keep the proof of delivery and the date and time of every call.
- Plan: an urgent appeal must be decided as soon as possible and no later than 72 hours after the plan receives it. Ask the plan to confirm the date and time it received the request.
- You: if waiting would seriously jeopardize life, health or ability to regain maximum function, ask about expedited external review at the same time. If the plan misses its deadline, see the letter on a missed deadline.
The rule behind this
- 29 CFR 2560.503-1(m)(1) (definition of urgent care claim)
- 29 CFR 2560.503-1(f)(2)(i), (i)(2)(i), (h)(3)(vi) (72 hours; oral and fast requests)
- 29 CFR 2560.503-1(b)(4) (authorized representatives in urgent cases)
- 29 CFR 2590.715-2719(b)(2)(ii)(B), (d)(3)(i) (deference to the provider; simultaneous expedited review)
Sources
- 29 CFR 2560.503-1(m)(1) (definition of urgent care claim)
- 29 CFR 2560.503-1(f)(2)(i), (i)(2)(i), (h)(3)(vi) (72 hours; oral and fast requests)
- 29 CFR 2560.503-1(b)(4) (authorized representatives in urgent cases)
- 29 CFR 2590.715-2719(b)(2)(ii)(B), (d)(3)(i) (deference to the provider; simultaneous expedited review)