Urgent / expedited appeal request letter

Template

{{MEMBER_NAME}}
{{MEMBER_ADDRESS}}
{{MEMBER_PHONE}}
Member ID: {{MEMBER_ID}}
Claim / Reference #: {{CLAIM_NUMBER}}
Date of Service: {{DATE_OF_SERVICE}}
Date of Denial Notice: {{DENIAL_DATE}}

{{INSURER_NAME}}
Appeals and Grievances Department
{{INSURER_APPEAL_ADDRESS}}

Re: Formal Internal Appeal — {{CLAIM_NUMBER}}

URGENT — EXPEDITED APPEAL REQUEST

I am requesting an expedited appeal of the denial dated {{DENIAL_DATE}} for {{SERVICE_OR_DRUG}}.

Under 29 CFR 2560.503-1(i)(2)(i) (and, where applicable, 45 CFR 147.136(b)(2)(ii)(C)(2)), the plan must decide an urgent appeal as soon as possible but not later than 72 hours.

Attached is a statement from my treating physician certifying that applying the standard appeal timeline would (a) seriously jeopardize my life, health, or ability to regain maximum function; and/or (b) subject me to severe pain that cannot be adequately managed without the requested care.

Please confirm receipt of this expedited appeal within 24 hours and issue your decision within 72 hours.

Sincerely,
{{MEMBER_NAME}}

Key points before you send it

• Expedited decisions must be made within 72 hours.
• Attach a physician statement that standard timing would jeopardize your health.