Build your case
Get your claim file and plan documents
Ask the plan for everything it relied on, and for the plan document that sets the rules.
Do this today
- Use the tool: Claim file request builder Build the letter asking your plan for everything it relied on, and get the date to follow up.
- Read: How to get your plan documents 5 minute read. Ask your plan administrator in writing for the summary plan description and the documents that set your plan's rules, so you can check the denial against them. Covers who to write to, cost and timing.
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Put this step on My Plan
So you can come back to it, and keep your dates and calls in one place.
In brief
- A job-based plan's administrator must, on written request, give you the latest summary plan description, the latest annual report and the documents under which the plan is run.
- Send the request in writing to the plan administrator named in your summary plan description, and keep proof of delivery.
- The plan may charge a reasonable copying fee of no more than 25 cents per page.
- Government, church and individual plans are outside this particular right. Ask anyway, and check your contract or state law.
More guides, tools and letters
More guides, tools, letters 12
Guides
- How to get your plan documents
Ask your plan administrator in writing for the summary plan description and the documents that set your plan's rules, so you can check the denial against them. Covers who to write to, cost and timing.
- How to read your claim file
Go through the file your plan sends. Find what it relied on, who reviewed your claim, what it missed and whether it kept to its own deadlines. Then your appeal can answer the real reason.
- How to request your claim file
Ask your plan in writing, before you appeal, for everything it used to decide your claim. Covers what to ask for, where to send it, what the rules say about cost and timing, and what to do if the plan stalls.
Tools
- Tool
Claim file request builder
Build the letter asking your plan for everything it relied on, and get the date to follow up.
- Tool
Denial letter checker
Tick what your denial letter contains and see what is missing and how to demand it.
Letters and scripts
- Letter or script
Ask for the clinical criteria used
A written request for the internal rule, guideline or clinical explanation the plan used to deny your care, so your appeal can answer it point by point. It is a records request, not an appeal.
- Letter or script
Ask for the parity comparison for a mental health denial
A written request for the plan's mental health parity comparison and the medical necessity criteria behind a mental health or substance use denial, so you can test the decision against the parity law.
- Letter or script
Ask for your claim file
A written request for everything the plan used or created when it decided your claim, sent before you appeal. It asks for the file free of charge and says clearly that it is not an appeal.
- Letter or script
Ask for your plan documents
A written request to your employer plan's administrator for the summary plan description and the documents that set the plan's rules, so you can check the denial against them.
- Letter or script
Ask who reviewed your claim and their credentials
A written request to learn who decided your claim and what medical experts the plan consulted, with their roles, specialties and licences. It is a records request, not an appeal.
Programs and services
- Program or service
Health Insurance Portability and Accountability Act right of access to your health information
The federal guidance on your right to see and get copies of your records held by your health plan and most providers, and to have them sent to someone you name.
From U.S. Department of Health and Human Services
- Program or service
ProPublica Claim File Helper
A free tool from ProPublica that builds a letter asking your health insurer for your claim file: the notes, call recordings and records it used to deny you. Request it before you appeal.
From ProPublica
Questions to keep handy
- What exactly was denied, and under which part of the plan?
- What is my deadline, and what is it counted from?
- Where and how do I send my request, and how will I prove it arrived?
- Who decides, and can I ask for a faster decision?
Not what you need? Find a person who can help, or search the whole site.