The Appeal Kit

What the Kit actually does: it owns the clock

Both sides of an appeal run on deadlines, and only one side is keeping track. The Kit computes yours and theirs from the date on your denial letter:

The day your plan misses its own deadline is the day you may stop waiting and go to review, deemed exhaustion, at 29 CFR 2560.503-1(l). It is a free escalation, and claiming it depends entirely on someone having counted the days on the insurer’s side. The Kit tells you the date it lands.

What is in it

• Your two deadlines, worked out from your denial date, with the expedited route explained.
• The argument that fits your denial reason, not medically necessary, out of network, experimental, administrative and the rest are each beaten differently.
• An evidence checklist: exactly which documents to request from the plan (they must give them to you free), and what to ask your clinician to write.
• A letter of medical necessity brief for your doctor, a clinician will write one; what decides it is whether it answers the criteria the reviewer applied.
• The external review request, the step 1 in 14,369 denials ever reaches, with what to include so it is not returned.
• What happens next, with the timeframes the plan must meet and what to do when they miss them.

See a real page from inside the Kit, free, right now

This is the document-request letter, complete and unredacted, the piece of the Kit that decides what your appeal can argue. It uses four federal rights to make your plan hand over its entire case before you write a word of your appeal. We publish it free because it proves what the rest of the Kit looks like. The Kit fills it in from your details and pairs it with the other five pieces.

[Your name]
[Your address]

[Today's date]

[Insurer name]
Appeals Department
[Address from your denial letter]

RE: Request for claim file and plan documents
    Member name: [Your name]
    Member ID: [Member ID]
    Claim / reference number: [Claim number]
    Date of service: [Date of service]
    Date of denial notice: [Date of denial]

To whom it may concern,

I am appealing the denial of the claim above. Before I submit my full appeal, I am
requesting the documents I am entitled to receive, so that my appeal can address the
actual basis of your decision.

Under 29 CFR 2560.503-1(h)(2)(iii), I am entitled, upon request and free of charge, to
reasonable access to and copies of all documents, records and other information relevant
to my claim. Paragraph (m)(8) defines what is relevant. On that basis I request:

1. The complete claim file, including everything relied upon in making this determination,
   and everything submitted, considered or generated in the course of making it, whether or
   not it was relied upon. (m)(8)(i) and (m)(8)(ii)

2. Any statement of policy or guidance held by the plan concerning the denied treatment or
   benefit for my diagnosis, whether or not it was relied upon in this decision. This
   includes the medical policy, clinical criteria, coverage guideline or technology
   assessment applied to my claim, and the date it was last reviewed. (m)(8)(iv)

3. The identification of any medical or vocational experts whose advice was obtained on
   behalf of the plan in connection with this determination, whether or not that advice was
   relied upon, including their specialty and board certification. (h)(3)(iv)

4. The documents demonstrating compliance with the administrative processes and safeguards
   required in making this determination. (m)(8)(iii)

5. The specific plan provision on which the denial relies, and the section of the plan
   document or Evidence of Coverage in which it appears.

6. A complete copy of the plan document or Evidence of Coverage in force on the date of
   service.

Please send these to the address above. I am also giving notice that I intend to appeal,
and I ask that this request not be treated as my appeal or as a substitute for it. I will
submit my full appeal within the applicable deadline.

If you consider that any part of this request falls outside what the regulation requires,
please say so in writing and identify which part and on what basis, rather than declining
the request as a whole.

Sincerely,


[Your name]
[Telephone]

Compare your options

Free letter generators exist. Here is the difference, stated plainly.

Several free services will draft an appeal letter from your denial notice, and several free guides now publish the ERISA rights. Documents are the commodity part of this. What none of them carry is state: none of them know your denial date, none of them detect whether you are in a self-funded plan where state external review does not apply, none of them count the insurer's 30- or 60-day clock, and none of them will tell you the day deemed exhaustion triggers or the day your four-month external window closes. A free letter filed into the wrong system, or on day 181, is a lost appeal with good paragraphs in it. The Kit is the sequencing layer that makes the documents land in the right place at the right time, and nothing you type into it leaves your browser, which is not true of the tools that process your denial on their servers.

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