Phone script: chase an appeal that has gone silent
What to say and ask when you have filed an appeal and heard nothing, including the federal decision deadlines for job-based and individual plans.
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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. When you filed an appeal with a job-based or individual plan and have not received a decision. Medicare and Medicaid have different deadlines: use the ones on your notice. Have your appeal date and your proof of how you sent it in front of you.
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 script
Your script
Date of this call: [Date of the call] 1. Say: "I am [Your name], member identification (ID) number [Member ID]. I filed an appeal for claim [Claim or reference number] on [Date you filed your appeal] by [How you sent it]. I have not received a decision." 2. Ask for the person's name and a call reference number. Ask whether the call may be recorded, and write down their answer. 3. Ask: "Did you receive my appeal? On what date? Is it complete?" 4. Ask: "By what date is my appeal due to be decided?" 5. Say: "Under the federal claims rules, an urgent appeal is due within 72 hours, an appeal about care I have not received within 30 days, and an appeal about care I already received within 60 days. If the plan has two appeal levels, each level has half of the 30 or 60 days. The 72-hour urgent limit does not change." 6. Ask: "Who is reviewing my appeal? Has a doctor reviewed it? Is anything missing from me?" 7. If the deadline has passed, say: "Please explain in writing why my appeal has not been decided." 8. Ask: "What will you do next, and by what date? Please confirm that in writing." 9. Write down: name, ID number, date, time, reference number, the promised action and the date. 10. Close: read your notes back and ask, "Is that right?" Say, "I will follow up in writing if I do not hear by that date."
Before you call
Call the appeals department number on your denial letter, or the member services number on the back of your insurance card. Ask for a call reference number at the start and again at the end of the call.
What happens next
- Follow up in writing the same day. Say what the plan told you and what date it promised.
- If a non-grandfathered plan or insurer does not strictly follow the appeal rules, you may be able to go straight to external review or to court. Ask your state insurance department, the Department of Labor or a lawyer how this applies to you.
- Keep the deadline for external review in view: for most job-based and individual plans, at least four months after a final denial. A grandfathered individual policy may give less. Check the date on your notice, which controls.