Letter: ask for an outside (external) review

Use this after your plan has made its final decision. Some states and the federal process also have their own form: check your state page.

Fill in your letter

Date of the letter (required)

Your state (required)

Your full name (required)

Your mailing address (required)

Where the reply should be sent.

Your email or phone (optional)

Who you are writing to (agency or program) (required)

Where is this review filed?

How will you send it?

Their mailing address (required)

Required when you mail it. The notice or the website lists it.

Member ID (optional)

Claim or reference number (optional)

Date on the denial notice (optional)

What was denied, reduced or ended (required)

In your own words, in English. Keep it short; you can add details in the extra line.

Reason the notice gave (optional)

This is urgent: waiting could seriously harm my health or ability to function. I ask for an expedited (fast) review.

Documents you are enclosing

The denial noticeA letter from my doctor explaining why the care is neededMedical records that support the requestExplanation of benefits (EOB)A copy of my insurance or Medicaid cardOther papers listed in my extra note

Anything else to add (optional, in English)

It goes into the letter as you type it.

Other formats

Sign the letter, keep a copy and keep proof of how and when you sent it (certified mail with a return receipt is one way). Do not wait for a reply to meet a deadline.

This is general information, not legal or medical advice. Health Appeal Map is not a law firm, not an insurer and not a government agency. Laws change, and what applies to you depends on your plan and your facts. Before you act, check the official sources on your state's page, or ask free legal help.