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Denial letter checklist: is anything missing?

Check a denial notice against the federal content rules for its plan type: commercial, grandfathered employer, Medicaid managed care or Medicare Advantage. Mark each item, see what is missing, and get a request letter that cites the rule for each gap.

By the ClaimParrot editorial team · Rules checked · 6 cited sources

Quick answer

A health plan denial notice must tell you more than “denied.” Federal rules require the specific reason, the plan provision or criteria relied on, how to appeal and by when, and, for urgent care, the expedited process. Commercial and Medicaid notices add more. Check the notice item by item and request anything missing in writing, without letting the appeal deadline slip.

Runs entirely in your browser. Nothing you type is sent to ClaimParrot or stored, and no patient details are needed: leave names and IDs as bracketed placeholders.

01 · The notice

Check the denial notice

Plan type on the notice

Most employer and individual plans: the ERISA claims rule plus the ACA notice rules for non-grandfathered coverage.

Read the notice once, then mark each item. Leave an item on “Not sure” if you cannot find it; the letter asks the plan to point to it.

  1. 01The specific reason for the denial

    A reason you could answer, not just a category such as “not medically necessary” with nothing behind it. (29 CFR 2560.503-1(g)(1)(i))

    Is “The specific reason for the denial” in the notice?

  2. 02The plan provision the decision is based on

    The section of the plan or policy the plan relied on. (29 CFR 2560.503-1(g)(1)(ii))

    Is “The plan provision the decision is based on” in the notice?

  3. 03The guideline or criteria relied on, or a statement that a copy is free on request

    For a medical-necessity or level-of-care denial, the criteria set and the criterion found unmet, or an offer to send them free. (29 CFR 2560.503-1(g)(1)(v)(A))

    Is “The guideline or criteria relied on, or a statement that a copy is free on request” in the notice?

  4. 04For medical-necessity denials: the clinical judgment applied to this patient, or a statement that it is free on request

    An explanation that applies the plan's terms to the patient's circumstances, not a generic definition of medical necessity. (29 CFR 2560.503-1(g)(1)(v)(B))

    Is “For medical-necessity denials: the clinical judgment applied to this patient, or a statement that it is free on request” in the notice?

  5. 05What extra information would support the claim, and why

    A description of any additional records or information that would change the decision. (29 CFR 2560.503-1(g)(1)(iii))

    Is “What extra information would support the claim, and why” in the notice?

  6. 06How to appeal and the time limits

    The appeal steps, where to send the appeal and how long you have. (29 CFR 2560.503-1(g)(1)(iv); 29 CFR 2590.715-2719(b)(2)(ii)(E)(4))

    Is “How to appeal and the time limits” in the notice?

  7. 07When the appeal can be expedited and how to ask

    The expedited or urgent review process for situations where waiting could seriously harm the patient's health. (29 CFR 2560.503-1(g)(1)(vi))

    Is “When the appeal can be expedited and how to ask” in the notice?

  8. 08The right to sue under ERISA section 502(a) after the appeal (employer plans)

    A statement of the right to bring a civil action after an adverse decision on appeal. It applies to employer plans, not individual policies. (29 CFR 2560.503-1(g)(1)(iv))

    Is “The right to sue under ERISA section 502(a) after the appeal (employer plans)” in the notice?

  9. 09Information that identifies the claim: date of service, provider and claim amount

    Enough to match the notice to the claim, plus a statement that the diagnosis and treatment codes and their meanings are available on request. (29 CFR 2590.715-2719(b)(2)(ii)(E)(1))

    Is “Information that identifies the claim: date of service, provider and claim amount” in the notice?

  10. 10The denial code and its meaning, and the plan standard used

    The reason code with its meaning, and a description of the plan's standard, if any, used to deny the claim. (29 CFR 2590.715-2719(b)(2)(ii)(E)(3))

    Is “The denial code and its meaning, and the plan standard used” in the notice?

  11. 11How to start an internal appeal and external review

    A description of the internal appeal and independent external review processes, including how to start an appeal. (29 CFR 2590.715-2719(b)(2)(ii)(E)(4))

    Is “How to start an internal appeal and external review” in the notice?

  12. 12Contact details for the consumer assistance office or ombudsman, if one applies

    The state office of health insurance consumer assistance or ombudsman that helps with appeals. (29 CFR 2590.715-2719(b)(2)(ii)(E)(5))

    Is “Contact details for the consumer assistance office or ombudsman, if one applies” in the notice?
You are writing as

02 · Result

What the notice is missing

0 of 12 found · 0 missing · 12 not sure

A missing item does not cancel the denial or stop the appeal clock. Request it in writing, keep the appeal deadline, and say in the appeal what was missing.

Request letter

[Your organization letterhead]
[Today's date]

[Plan name]
[Appeals or member services address or fax, from the notice]

Re: Request for information missing from a notice of adverse benefit determination
Member: [Member name]    Member ID: [Member ID]
Claim or authorization number: [Claim or authorization number]
Notice date: [Notice date]    Dates of service: [Dates of service]

We are writing as the treating provider about the adverse benefit determination in the notice above.

We could not find the following in the notice. If it was provided, please tell us where:

1. The specific reason for the denial (29 CFR 2560.503-1(g)(1)(i))
2. The plan provision the decision is based on (29 CFR 2560.503-1(g)(1)(ii))
3. The guideline or criteria relied on, or a statement that a copy is free on request (29 CFR 2560.503-1(g)(1)(v)(A))
4. For medical-necessity denials: the clinical judgment applied to this patient, or a statement that it is free on request (29 CFR 2560.503-1(g)(1)(v)(B))
5. What extra information would support the claim, and why (29 CFR 2560.503-1(g)(1)(iii))
6. How to appeal and the time limits (29 CFR 2560.503-1(g)(1)(iv); 29 CFR 2590.715-2719(b)(2)(ii)(E)(4))
7. When the appeal can be expedited and how to ask (29 CFR 2560.503-1(g)(1)(vi))
8. The right to sue under ERISA section 502(a) after the appeal (employer plans) (29 CFR 2560.503-1(g)(1)(iv))
9. Information that identifies the claim: date of service, provider and claim amount (29 CFR 2590.715-2719(b)(2)(ii)(E)(1))
10. The denial code and its meaning, and the plan standard used (29 CFR 2590.715-2719(b)(2)(ii)(E)(3))
11. How to start an internal appeal and external review (29 CFR 2590.715-2719(b)(2)(ii)(E)(4))
12. Contact details for the consumer assistance office or ombudsman, if one applies (29 CFR 2590.715-2719(b)(2)(ii)(E)(5))

Please also send, free of charge, the criteria set, edition and specific criterion applied, and copies of all documents, records and other information relevant to this decision.

This letter is a request for information. It is not an appeal. Please confirm in writing the deadline to file an appeal of this decision; we intend to file within it.

Sincerely,

[Name, credentials, title]
[Organization, phone, fax, mailing address]

[If the plan requires it, attach an authorized representative form signed by the member, or cite your provider agreement.]

Drafted with the free ClaimParrot denial letter checklist (claimparrot.com/tools/denial-notice-checklist). General information, not legal advice; state law and the plan documents may require more.

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How it works

The rules behind the tool

Who sets the notice rules, by plan type
Plan typeMain notice ruleNotable extras
Employer plan (ERISA), grandfathered29 CFR 2560.503-1(g)Criteria or guideline relied on, clinical judgment, right to sue under section 502(a)
Employer or individual plan, non-grandfathered29 CFR 2560.503-1(g) plus 29 CFR 2590.715-2719(b)(2)(ii)(E); 45 CFR 147.136 for individual coverageClaim identifiers, denial code and meaning, external review, consumer assistance contact
Medicaid managed care42 CFR 438.404Free copies of documents and criteria, State fair hearing, continued benefits
Medicare Advantage42 CFR 422.568Standard and expedited reconsideration, CMS-approved notice language
01

How do I use the denial letter checklist?

Pick the plan type printed on the notice, then mark each required item as in the notice, missing or not sure. The result lists what is missing and drafts a letter asking the plan for it, citing the rule for each item. Keep bracketed placeholders for names and ID numbers; nothing you enter leaves the browser.

  1. 01Find the plan type: the notice, the member's card or the plan documents usually say whether it is an employer plan, an individual policy, Medicaid managed care or Medicare Advantage.
  2. 02Read the notice once from start to finish, including enclosures and the back pages, where appeal rights often sit.
  3. 03Mark each item. Use “Not sure” when the notice is vague, such as a reason with no explanation behind it.
  4. 04Review the request letter, fill the placeholders, and send it to the address or fax the notice gives for appeals or member services.
  5. 05Calendar the appeal deadline from the notice. The request for information does not pause it.
02

Why does the content of a denial notice matter for the appeal?

You can only answer the reason and criteria you can see. A notice without the specific reason, the guideline relied on or the clinical rationale leaves the appeal guessing. Asking for the missing pieces early gives the clinician something concrete to answer, and puts on record that the plan's notice was incomplete.

For medical-necessity and level-of-care denials the most useful items are the criteria and the clinical judgment applied to the patient. Under the ERISA rule, a group health plan must either include them or say they are available free on request. Parity rules separately require plans to disclose medical-necessity criteria for mental health and substance use benefits on request (29 CFR 2590.712). The denial notice requirements guide covers each element in depth.

03

What can I do when the notice is missing required information?

Ask for it in writing, keep a dated copy, and file the appeal on time anyway. In the appeal, state what the notice left out and when you asked. For non-grandfathered commercial plans, a plan that fails to follow the claims rules can, apart from minor errors, lose the right to insist on its internal appeal first.

That last point is the ACA's deemed-exhaustion rule (29 CFR 2590.715-2719(b)(2)(ii)(F)), which has an exception for minor violations that do not cause harm, so treat it as a fact to state, not a shortcut. For criteria and the claim file, the criteria request letter asks for both. For Medicaid enrollees, the plan must give the case file, including medical records and criteria, free of charge.

A request for information is not an appeal, and it does not stop the appeal clock. Use the appeal deadline calculator and file inside the window the notice states.

04

Why do the required items differ by plan type?

Different federal rules govern each kind of coverage. Employer plans follow the ERISA claims rule; non-grandfathered employer and individual plans add the ACA notice requirements; Medicaid managed care plans follow 42 CFR 438.404; Medicare Advantage plans follow 42 CFR 422.568. State law can add requirements for state-regulated coverage.

If the notice does not say what kind of plan it is, ask the plan or check the member's plan documents. Self-funded employer plans are generally not regulated by state insurance law, while insured plans and individual policies usually are, which can add state-specific notice items and longer appeal windows. When in doubt, mark the commercial items: the extra ACA items are a superset.

Fictional example

A residential denial with no criteria named

Marsh Creek Recovery (fictional) receives a notice from an employer plan: residential SUD treatment is “not medically necessary.” The UR lead runs the checklist for a commercial plan. The reason, appeal steps and deadline are present; the guideline relied on, the clinical rationale and the denial code meaning are missing.

She sends the request letter the same day, calendars the 180-day member appeal window and the program's shorter contract deadline, and asks the attending physician to start the clinical statement. When the plan's criteria arrive, the team answers them dimension by dimension in the appeal.

Names, dates, payers and amounts are invented for illustration.

Where ClaimParrot fits

What a ClaimParrot packet adds

  • An appeal packet starts from the reason the notice states, adds an evidence checklist and a deadline plan, and flags a notice that names no criteria, with a person checking it before delivery.
  • Appeal packets are $29 and level-of-care packets $99, each within 3 business days; the first packet is free. See pricing.
  • Send the denial de-identified: no names, ID numbers or calendar dates. How requests are handled is on Trust & security.

Every draft is reviewed and approved by your team. ClaimParrot does not make medical-necessity determinations or give legal advice.

Common questions

Frequently asked questions

Does a missing item make the denial invalid?

Not by itself. It is a procedural defect to point out and, for non-grandfathered commercial plans, it can matter under the deemed-exhaustion rule. The denial still stands until the plan or a reviewer changes it, so keep the appeal deadline.

Can I ask for the diagnosis and treatment codes without starting an appeal?

Yes. For non-grandfathered commercial plans, the notice must say the codes and their meanings are available on request, and the plan may not treat that request, by itself, as an appeal or external review request.

Who should send the request letter: the provider or the member?

Either can, depending on the plan. Many ERISA rights belong to the member or an authorized representative, so attach the plan's representative form if the plan requires it. Providers can also ask under their network agreement.

Does the checklist cover state notice rules?

No. It covers the federal floor. State-regulated plans can owe more, such as state-specific appeal rights or language rules. Check the state insurance department or Medicaid agency pages for the plan's state.

Sources

Primary sources and references

  1. 29 CFR 2560.503-1: ERISA claims procedure (appeal windows, decision clocks, claim-file access) · eCFR (National Archives) · checked
  2. 29 CFR 2590.715-2719: internal claims, appeals and external review (group health plans) · eCFR (National Archives) · checked
  3. 45 CFR 147.136: internal claims, appeals and external review (issuers, individual market) · eCFR (National Archives) · checked
  4. 42 CFR 438.404: Medicaid managed care notice of adverse benefit determination (content and timing) · eCFR (National Archives) · checked
  5. 42 CFR 422.568: standard organization determination timeframes · eCFR (National Archives) · checked
  6. 29 CFR 2590.712: MHPAEA parity requirements and criteria disclosure · eCFR (National Archives) · checked

General information, not legal or medical advice. The denial notice, the plan documents and state law control; state law can give more time or more rights than the federal floor shown here. Read our editorial policy.

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