More information needed

What it means

The plan has written to ask for something before it will decide: medical records, a form, an answer about other coverage or an accident, or a missing detail. This is usually a request, not a final decision. If the plan does not receive what it asked for, it may deny the claim for that reason, and then it is a denial you can appeal.

Look for two things in the letter: what exactly is missing, and the date by which the plan wants it.

Who has to act first

You and your provider, each for your own part. The notice must state any additional material needed to complete the claim and why it is needed. If it does not, call the plan and ask for the list in writing.

Know your minimum time to answer:

• A claim that is not urgent: at least 45 days to supply the information.
• An urgent claim: the plan must tell you what is missing within 24 hours, give you at least 48 hours to supply it, and decide within 48 hours after it receives the information or after the time to supply it ends.
• A request sent the wrong way: if a request for approval before care reaches the right unit and names you, your condition and the treatment, the plan must tell you the correct procedure within 5 days (24 hours if urgent).

Check the date on your notice, which controls. These are federal minimums, and your plan or state may give more.

Arguments that work

• Ask what is missing, in writing. A vague request can be answered with a question: which item, in what form, sent where.
• You were not given enough time. If you had fewer than 45 days for a claim that is not urgent, say so in writing and cite the federal claims rule.
• You sent it. A fax confirmation, a portal receipt or a certified mail receipt with a date shows the plan had it. Ask the plan to confirm receipt.
• The request goes beyond what is needed. Ask which plan provision requires each item.
• Records take time. A provider or plan must act on a request for your own records within 30 days, with one extension of up to 30 more days if it explains the delay in writing. Ask early, and ask the provider to send records straight to the plan.
• Ask for a bill hold. Ask your provider in writing to hold the bill while the claim is pending; it is not required to, and an unpaid bill can go to collections, so ask before you withhold any payment.

Evidence to gather

• The letter asking for information, with its date and the deadline (you).
• A list of each item the plan wants and who holds it (you).
• Medical records and codes (your provider).
• Forms the plan sent you (you).
• Proof of sending: confirmations, receipts and tracking numbers (you, your provider).
• Your call log (you).

What to send

Send a cover note that lists each item, the claim number and any reference number. Use a method that proves the date. A few days later, call the plan to confirm it received everything and ask when it will decide. Keep the confirmation.

When this is not worth an appeal

While the plan is only asking for information, there is nothing to appeal yet, and an appeal that leaves the item out does not answer the plan. Send what it asked for first. If it has already denied the claim for lack of information, send the information with your appeal, inside your deadline of at least 180 days after you receive the denial for a job-based plan or a non-grandfathered individual plan. Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different, often shorter, deadlines.