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Insurance Appeal Checklist

Sometimes your insurance company will say no to covering the cost of a prescription or medical service. If this happens, you can appeal. Use this handy checklist to make sure you don’t miss any important steps in the process.

Every insurance type and plan has a different appeal process. Although there is no uniform way to appeal, the following are the most common steps in most processes.

  1. Call the phone number on the back of your health insurance ID card. Sometimes it will say “member services” next to the phone number.
  2. Ask the person on the phone to send you information on how to appeal.\
  3. Put the appeal in writing.
    Sometimes there’s a specific form you need to use. Sometimes you can write a letter. The forms and letters usually need to include:
    • Your name
    • Your address
    • Your phone number
    • Your doctor’s name
    • Your doctor’s address
    • Your doctor’s phone number
    • Your insurance ID number
    • Dates of your claim determination
    • The name of the drug or service you want your insurance to cover
    • Reason(s) why you are appealing the decision
  4. Include additional information.
    Some of those items include:
    • A copy of your insurance card (both sides)
    • The document that said you were denied (called a coverage determination) from your pharmacy or insurance company
    • If you have an appointed representative, a copy of the “appointment of representative” form
    • Supporting medical documents from your doctor
    • Any other information that may help       
  5. Fax or mail the information to the insurance company.
    For the fax number or mailing address, call the phone number on the back of your insurance ID card.

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