Checklist · Healthcare

Appealing a Health Insurance or Medicare Denial: A Practical Checklist

29 U.S.C. § 1024

Type: Checklist
Jurisdiction: National
Date: 2024-11-26
Topic: Healthcare

This checklist takes a health coverage denial from the letter on the table to a resolved claim. Phase 1 is triage, which identifies the system, the stated reason, and the deadline in fifteen minutes, and Phase 2 is the claim file request that decides most cases. Phases 3 and 4 cover the internal appeal, how to build it around the plan's own criterion, and when to demand expedited review. Phase 5 covers external review by an independent organization whose decision binds the plan. Phase 6 covers the Medicare ladders and the fast-track termination review measured in hours. Phases 7 and 8 cover free regulator complaints and the hospital bill, both of which run in parallel with the appeal. Phase 9 covers litigation and the contractual deadline that precedes it. Four model letters, a deadline table, and a ranked failure-mode list close the checklist.

Appealing a Health Insurance or Medicare Denial: A Practical Checklist

Healthcare > Health Coverage Appeals | Published 26 November 2024 - Updated 14 July 2025 | UpLaw - uplaw.us

If the denial concerns care happening right now — a skilled nursing stay, a hospital discharge, home health, hospice — skip to Phase 6 and act today. That clock is measured in hours.

Keywords: triage, claim file, internal appeal, expedited, external review, Medicare, complaints, billing

How to use this checklist

Nine phases with - [ ] items and a Why it matters, and the traps note under each.

Doctrine is in Health Coverage Denials and Appeals: A Comprehensive Guide to ERISA Plans, Marketplace Coverage, and Medicare. The narrative is Denied: What to Do When a Health Plan Says No. The forms are in The Health Coverage Appeal Toolkit.

Phase 1 — Triage

[ ] Read the denial letter completely, twice.
[ ] Identify the specific stated reason: not medically necessary · experimental · out of network · benefit exclusion · coding or eligibility · prior authorization not obtained · no longer meets continued-stay criteria.
[ ] Identify every deadline on the letter and calendar each one.
[ ] Determine the system: self-funded employer plan · fully insured plan or marketplace policy · Medicare · Medicare Advantage · Medicaid.
[ ] If unsure, ask the employer's benefits office or read the summary plan description.
[ ] Determine whether the care is ongoing — if so, go to Phase 4 and Phase 6 today.
[ ] Note whether expedited review may apply.
[ ] Collect the explanations of benefits for the service.
[ ] Ask the provider's billing office whether this is actually a coding or eligibility problem.
[ ] Write the reason, the system, and the deadlines on one page.

Why it matters, and the traps. Answering the wrong reason is the most common error in this practice. A medical necessity appeal against an out-of-network denial loses on a point nobody made.

And a coding denial is not an appeal at all — it is a corrected claim. Calling the billing office first takes ten minutes and resolves a meaningful share of denials without any appeal.

Phase 2 — The claim file

[ ] Request, in writing, the complete claim file.
[ ] Cite 29 C.F.R. Part 2560 for an ERISA plan.
[ ] Request the specific clinical criterion, guideline, or protocol applied, in full.
[ ] Request the identity, credentials, and specialty of every reviewer.
[ ] Request any medical opinion or peer review obtained.
[ ] Request the plan document and summary plan description under 29 U.S.C. § 1024 and 29 U.S.C. § 1022.
[ ] Request any compensation arrangement bearing on reviewer independence.
[ ] Note that these must be provided free of charge.
[ ] From the plan document, extract the definition of medical necessity, the exclusions, the grant of discretionary authority, and the contractual limitations period.
[ ] Compare the criterion to what the plan actually received.

Why it matters, and the traps. This is the step that decides most appeals, and it happens before any argument is written.

The most productive discovery is almost always the same one: the criterion was applied to a record that did not contain the documents satisfying it. Those documents exist. They were never sent.

And find the contractual limitations period now. It is frequently shorter than any state statute and courts enforce it.

Phase 3 — The internal appeal

[ ] State the relief requested in the first sentence.
[ ] Quote the plan's stated reason.
[ ] Quote the criterion, from the plan's own document.
[ ] Map the record to the criterion, element by element, with tabbed exhibits referenced by letter.
[ ] Obtain a physician letter that addresses the criterion by its own terms — not a conclusory assertion.
[ ] Include a patient statement in concrete functional language.
[ ] For an experimental or investigational denial, include peer-reviewed literature and professional society guidelines.
[ ] For a behavioral health denial, also request the comparable medical criterion and the plan's comparative analysis, and raise parity.
[ ] Preserve every procedural objection: reviewer specialty · undisclosed criterion · missed deadline · incomplete record · new evidence relied on without an opportunity to respond.
[ ] Keep it under five pages, tabbed, with an index.
[ ] Exhaust every internal level the plan requires.
[ ] Send by a method producing proof of delivery.

Why it matters, and the traps. In an ERISA case the record closes here. Under Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989), a court reviewing a plan with discretionary authority asks whether the decision had any reasonable basis in the administrative record — and Metropolitan Life Insurance Co. v. Glenn, 554 U.S. 105 (2008) makes the plan's structural conflict a factor rather than a disqualification.

Holding evidence back for litigation is the single most damaging strategic error available.

Phase 4 — Expedited review

[ ] Determine whether delay would seriously jeopardize life, health, or the ability to regain maximum function.
[ ] Or whether delay would subject the claimant to severe pain that cannot be adequately managed.
[ ] Request expedited review by name, in writing.
[ ] Have the treating physician state the basis in writing.
[ ] Ask whether expedited external review may run concurrently with the internal appeal.
[ ] Confirm the plan's decision deadline for an expedited claim and calendar it.
[ ] Follow up by telephone the same day and document the call.
[ ] Escalate to a supervisor if the request is not acknowledged.
[ ] If refused, preserve the refusal as a procedural objection.
[ ] Continue building the full record in parallel.

Why it matters, and the traps. Expedited review is routinely available and routinely not requested. The standard is not extraordinary, and the physician's statement is usually a paragraph.

A refusal to expedite where the standard was met is itself an argument, and it should be documented at the time rather than reconstructed later.

Phase 5 — External review

[ ] Confirm internal appeals are exhausted — or that the plan's procedural failures excuse exhaustion.
[ ] Confirm the denial involves medical judgment — medical necessity, appropriateness, level of care, effectiveness, or experimental status — or a rescission.
[ ] Note that a pure contract question, such as a clear categorical exclusion, is generally outside external review.
[ ] Identify the applicable process: the state external review program, or the federal process under 42 U.S.C. § 300gg-19 and 45 C.F.R. Part 147.
[ ] Confirm the deadline — commonly four months from the final internal denial.
[ ] Submit the complete record, organized as in Phase 3.
[ ] Add anything new that supports the clinical case.
[ ] Request expedited external review if the situation is urgent.
[ ] Confirm the review is free to the claimant.
[ ] Note the decision binds the plan.

Why it matters, and the traps. This is the most underused right in health coverage. The reviewer is an independent clinician in the appropriate specialty, the decision binds the plan, and it costs nothing.

It applies to self-funded ERISA plans as well as insured ones. Rush Prudential HMO, Inc. v. Moran, 536 U.S. 355 (2002) established that a state independent review requirement survives ERISA preemption as a law regulating insurance; the federal requirement now reaches the rest.

The four-month deadline is forfeitable and is missed constantly, because by then the claimant has been fighting for months and assumes the process is over.

Phase 6 — Medicare

[ ] Identify Original Medicare or Medicare Advantage.
[ ] If a service is being terminated — skilled nursing, home health, hospice, or comprehensive outpatient rehabilitation — request the quality improvement organization fast-track review immediately.
[ ] Note that deadline is generally by noon the day before coverage ends.
[ ] Note that a timely request continues coverage pending the decision, and the review is free.
[ ] For a hospital discharge believed premature, request the analogous immediate review.
[ ] Obtain the therapy and nursing notes supporting continued need.
[ ] Argue the correct standard — improvement is not always required; skilled care to maintain function or prevent deterioration can qualify.
[ ] For Original Medicare, work the ladder under 42 U.S.C. § 1395ff: redetermination → reconsideration → ALJ hearing → Appeals Council → district court.
[ ] For Medicare Advantage, work the ladder under 42 U.S.C. § 1395w-22: organization determination → plan reconsideration → automatic independent review → ALJ → Council → court.
[ ] Request expedited determinations and reconsiderations where the standard timeframe could jeopardize health.
[ ] Contact the free state health insurance assistance program for help at any level.

Why it matters, and the traps. The fast-track termination review is the most commonly forfeited right in this checklist, because a notice handed to a family in a facility hallway does not look like a deadline measured in hours.

The Medicare Advantage automatic independent review is unusual and valuable: an adverse plan reconsideration goes to an outside entity without the beneficiary doing anything.

Phase 7 — Complaints and regulators

[ ] For a fully insured plan or marketplace policy, file with the state insurance regulator.
[ ] For an ERISA plan, contact the Department of Labor's benefits advisors.
[ ] For Medicare, use the beneficiary help line and the state health insurance assistance program.
[ ] For a facility-related coverage dispute, contact the long-term care ombudsman.
[ ] For a Medicaid denial, follow the state fair hearing process under 42 C.F.R. Part 431.
[ ] Ask the hospital's patient advocate or case manager for help assembling the clinical record.
[ ] Contact a disease-specific patient advocacy organization — many maintain appeal templates and literature for the exact denial.
[ ] File complaints in parallel with the appeal, not instead of it.
[ ] Keep every written response.
[ ] Note that complaints do not extend appeal deadlines.

Why it matters, and the traps. All of these are free, and several generate written responses that resolve matters without further process.

The trap is substitution. A complaint is not an appeal, and the appeal deadline keeps running while the complaint is pending.

Phase 8 — The bill

[ ] Demand an itemized bill, not a summary.
[ ] Compare it line by line to the explanation of benefits.
[ ] Look for duplicate charges, services not rendered, wrong units, and wrong codes.
[ ] Ask about the hospital's financial assistance policy — thresholds are frequently higher than expected.
[ ] Ask for the self-pay or prompt-pay rate.
[ ] Negotiate. Billed charges are a starting number.
[ ] Ask for an interest-free payment plan.
[ ] Do not convert the debt to a credit card or medical credit line without understanding the consequence.
[ ] If it reaches collection, send a validation request under 15 U.S.C. § 1692g and screen conduct under 15 U.S.C. § 1692e.
[ ] Dispute any inaccurate reporting under 15 U.S.C. § 1681i and 15 U.S.C. § 1681e.

Why it matters, and the traps. Run this in parallel with the appeal. They are different processes with different decision-makers, and sequencing them costs deadlines in both.

The itemized bill is the only way to find errors, and errors are common.

Phase 9 — Litigation

[ ] Confirm administrative remedies are exhausted.
[ ] Locate the contractual limitations period in the plan document and calendar it.
[ ] Understand the action lies under 29 U.S.C. § 1132 for an ERISA plan.
[ ] Expect no jury, no new evidence, and no damages beyond the benefit.
[ ] Determine the standard of review — does the plan grant discretionary authority? See Firestone.
[ ] Develop the structural conflict argument under Glenn, including any compensation arrangement obtained in Phase 2.
[ ] Note that a prior administrator error does not forfeit deference — Conkright v. Frommert, 559 U.S. 506 (2010).
[ ] Assess whether state claims survive 29 U.S.C. § 1144 preemption and Aetna Health Inc. v. Davila, 542 U.S. 200 (2004) — generally not for a self-funded plan.
[ ] Consider equitable relief under the catchall provision per CIGNA Corp. v. Amara, 563 U.S. 421 (2011).
[ ] Assemble the complete administrative record as the operative evidence.

Why it matters, and the traps. Litigation reviews the record; it does not create one. Everything that matters had to go in during Phase 3.

The contractual limitations period is the trap. It is shorter than any state statute, it is buried in the plan document, and courts enforce reasonable ones.

Model letters

A. Claim file request

"Re: [patient], member ID [], claim [], denial dated [___]. Pursuant to the claims procedure regulation, I request, free of charge, all documents, records, and other information relevant to this claim, including: the complete claim file; the specific clinical criteria, guidelines, protocols, or policies relied upon, in full; the identity, credentials, and specialty of each individual who reviewed the claim; any medical opinion or peer review obtained; the plan document and summary plan description; the administrative services agreement; and any compensation arrangement bearing on reviewer independence. Please confirm the deadline for the internal appeal."

B. Internal appeal

"Re: [patient], claim [___]. I request that the plan approve the [service] denied on [date].

The plan's stated reason is that the service is not medically necessary. The criterion the plan supplied provides: '[quote].'

Criterion (a) — documented failure of conservative therapy. The patient completed twelve weeks of physical therapy from [date] to [date]; discharge summary at Tab B. Criterion (b) — imaging confirming the diagnosis. MRI dated [date] at Tab C. Criterion (c) — documented functional limitation. Treating physician's letter at Tab A; patient statement at Tab D.

Procedural objection. The reviewer is identified as a [specialty], not [required specialty], contrary to the requirement of consultation with a professional in the appropriate field. This objection is preserved."

C. Expedited review request

"Re: [patient], claim [___]. I request expedited review. Application of the standard timeframe would seriously jeopardize the patient's life, health, and ability to regain maximum function, and would subject the patient to severe pain that cannot be adequately managed. The treating physician's statement to that effect is enclosed. Please confirm receipt today and advise the decision deadline."

D. External review request

"Re: [patient], claim []. Internal appeals were exhausted by the final adverse determination dated []. I request external review by an independent review organization. The denial rests on a medical judgment — [medical necessity / level of care / experimental or investigational determination] — squarely within the scope of external review. The complete record is enclosed and indexed. [If urgent] I request expedited external review."

The deadline table

Step	Typical window	Consequence of missing it
Medicare fast-track review	By noon the day before coverage ends	Coverage stops; free review forfeited
Hospital discharge immediate review	Same day, per the notice	The review and the covered days
Expedited internal appeal	Days	The service is delayed
Internal appeal	Commonly 180 days from the denial	The right to appeal at all
Second-level internal appeal	Per the plan	No progression to external review
External review	Commonly 4 months from the final internal denial	A free, independent, binding review
Medicare redetermination	Months from the initial determination	Level one
Medicare reconsideration	Months from the redetermination	Level two
ALJ hearing	Months from the reconsideration	Level three
ERISA suit	The plan's contractual limitations period	The claim

The first two rows are measured in hours. The sixth is the one nobody knows exists. The last is buried in the plan document.

Who does what

The patient or family. Phase 1's triage and Phase 2's written request. Neither requires a professional, and together they identify every deadline and most of the argument.

The treating physician's office. The physician letter in Phase 3, and — more valuably — the habit of sending the complete record with every prior authorization request, which prevents a large share of denials before they happen.

A hospital patient advocate or case manager. Phases 3 and 6. They file these appeals constantly and can assemble the clinical record faster than anyone. Ask.

Free counselors and regulators. Phase 7 in its entirety — the state insurance regulator, the Department of Labor, the state health insurance assistance program, the long-term care ombudsman.

A patient advocacy organization. Frequently holds appeal templates and literature for the exact denial at issue.

An ERISA benefits attorney. Where the claim is large, the care is ongoing and high-cost, the denial is a long-term disability termination, or the plan has ignored the procedural requirements. Involve counsel before the record closes, not after.

And where the denial is Medicaid rather than insurance, the process is a state fair hearing — see Applying for Medicaid Long-Term Care Coverage: A Practical Checklist and Medicaid and Long-Term Care: A Comprehensive Guide to Eligibility, Transfers, Estate Recovery, and Appeals.

Failure modes, ranked

Not appealing at all.
Missing the Medicare fast-track deadline on a service termination.
Never requesting the claim file and the criterion.
Answering the wrong denial reason.
Not knowing external review exists.
Holding evidence back for litigation, when the record closes at the end of the internal appeal.
A conclusory physician letter instead of one that maps the criterion.
Not requesting expedited review where the standard is met.
Missing the contractual limitations period.
Failing to preserve procedural objections.
Treating a regulator complaint as a substitute for the appeal, while the deadline runs.
Not calling the billing office on what turns out to be a coding denial.
Ignoring the bill while the appeal proceeds.
Not raising parity on a behavioral health denial.

Items 1, 2, and 3 account for most lost coverage, and none of the three requires a lawyer to avoid.

Appealing a Health Insurance or Medicare Denial: A Practical Checklist

How to use this checklist

Phase 1 — Triage

Phase 2 — The claim file

Phase 3 — The internal appeal

Phase 4 — Expedited review

Phase 5 — External review

Phase 6 — Medicare

Phase 7 — Complaints and regulators

Phase 8 — The bill

Phase 9 — Litigation

Model letters

A. Claim file request

B. Internal appeal

C. Expedited review request

D. External review request

The deadline table

Who does what

Failure modes, ranked

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