Use this checklist to organize a disputed coverage or payment decision. Copy it to paper or a private document; this page does not collect records, send an appeal, or promise a result. Guidance was checked November 2, 2026. Appeal rights, deadlines, and review routes depend on the coverage program, plan, decision, and urgency.
1. Identify the decision and coverage
- Date the notice was issued and date you received it: ______.
- Insurer or program, plan name, and coverage type: ______.
- Decision being challenged: service denied, payment denied, coverage ended, or another issue: ______.
- Service date and provider, if relevant: ______.
- Reason and policy provision cited in the notice: ______.
- Outcome you want: ______.
Keep the original notice, envelope or delivery evidence, Explanation of Benefits, and relevant bill. An Explanation of Benefits is not itself a provider bill. A deductible or coinsurance charge is not necessarily a coverage denial; the cost-sharing guide can help you read the terms.
A Marketplace decision about eligibility or financial help uses a different process from an insurer's denial of medical benefits. Medicaid agency decisions and Medicaid managed-care decisions also need their own notice-specific route. Do not assume the private-plan process below covers every program.
2. Preserve the correct deadline
Copy the appeal instructions from your actual notice into your private record:
- First appeal recipient, address or approved electronic channel: ______.
- Filing deadline and whether receipt or sending controls: ______.
- Form or required information: ______.
- Urgent or expedited review contact: ______.
- Representative authorization requirement: ______.
- Person who confirmed unclear instructions and date: ______.
HealthCare.gov describes a 180-day internal appeal filing period for the private insurance process it explains. The Department of Labor's ERISA guidance describes at least 180 days for an initial health-benefit appeal, with plan-specific procedures and exceptions. These are not universal deadlines for Medicare, Medicaid, every subsequent appeal level, or urgent service-termination cases.
Medicare has separate appeal routes for Original Medicare, Medicare health plans, and drug plans. Use the notice and program instructions. If waiting could seriously harm health or services are ending, contact the clinician and designated appeal office promptly about the appropriate fast process; do not wait for a routine calendar reminder.
3. Gather a focused evidence packet
Check each item as you obtain it:
- Denial notice and claim or authorization reference, stored privately.
- Relevant policy or plan provision and requested clinical criteria.
- Relevant medical records and clinician explanation addressing the stated reason.
- Prior authorization, referral, or network evidence when relevant.
- Itemized bill and corrected billing information if an error is suspected.
- Signed representative form when required.
- Dated call log and copies of previous submissions.
Ask what records the plan relied on and how to obtain relevant documents. For plans subject to ERISA's claims rules, the Department of Labor describes access to relevant claim records without charge. Keep medical evidence focused on the disputed decision and send it only through the designated secure route.
A billing correction or telephone inquiry may resolve a mistake, but do not assume it stops the appeal clock. If the deadline is approaching, ask the responsible office how to preserve an appeal while additional evidence is gathered.
4. Write and send the request
Use this outline, adapting it to the required form:
- Identify the decision and the person covered, using identifiers only in the private submission.
- State clearly that you are appealing and specify the requested correction.
- Address each stated denial reason using the plan terms and supporting facts.
- Number the attached documents and explain why each matters.
- Request expedited handling when appropriate, supported by the clinician's explanation.
- Ask for confirmation of receipt and a written decision.
Save a complete copy before sending. Record submission date, method, delivery proof, case number, and the stated response deadline. A portal upload confirmation should be retained just as carefully as postal delivery evidence.
5. Review the response and preserve further rights
If the decision remains unfavorable, read the new notice for another internal level, external review, program appeal, or other available route. HealthCare.gov's external review guidance describes a four-month filing period for the process it explains, including eligible medical-judgment disputes. State and federal arrangements, plan applicability, and urgent exceptions matter; external review is not available for every disagreement.
- Response received and date: ______.
- Further review route and exact deadline: ______.
- Additional evidence or form needed: ______.
- Assistance contacted and next action date: ______.
For an employer plan, the plan administrator and Department of Labor may help identify the process. For insured coverage, a state insurance department or Consumer Assistance Program may help; Medicare and Medicaid use their respective program channels. A complaint to a regulator is not automatically an appeal. Keep both tracks documented, and seek qualified assistance when a deadline, legal right, or ongoing treatment is at risk.