ERISA claim file and plan-criteria request: letter generator

7 paragraphs included — written as the practice, as the patient's authorized representative

[PRACTICE NAME]
[PRACTICE ADDRESS]
[PRACTICE PHONE]

[DATE]

[PLAN NAME] - Claims Appeal Unit
[APPEALS ADDRESS FROM THE NOTICE]

Re: Request under 29 CFR 2560.503-1 for documents relevant to a denied dental claim

Patient: [PATIENT NAME] - DOB: [DATE OF BIRTH]
Member/subscriber ID: [MEMBER ID] - Plan: [PLAN NAME]
Claim number: [CLAIM NUMBER] - Date(s) of service: [DATE OF SERVICE]
Procedure code(s): [PROCEDURE CODES] - Amount billed: [BILLED AMOUNT]
Denial notice dated: [DATE OF DENIAL NOTICE] - Denial code(s): [DENIAL CODES]

This office is writing about the dental claim identified above, which the plan denied by notice dated [DATE OF DENIAL NOTICE]. This office submits this request as the patient's authorized representative. The notice states the service was denied as not medically necessary or under a similar clinical exclusion or limit. This letter requests the record behind that determination so that any appeal addresses what the plan actually applied.

Under 29 CFR 2560.503-1(h)(2)(iii), please provide, free of charge, reasonable access to and copies of all documents, records, and other information relevant to this claim.

Relevance is defined by paragraph (m)(8). Please read this request as reaching all four categories: material relied upon; material submitted, considered, or generated in the course of making the determination, whether or not relied upon; material demonstrating compliance with the administrative processes and safeguards required by paragraph (b)(5); and any statement of policy or guidance concerning the denied treatment for this diagnosis, whether or not relied upon.

If an internal rule, guideline, protocol, or other similar criterion was relied on, please send a copy. 29 CFR 2560.503-1(g)(1)(v)(A) requires the denial notice either to state that criterion or to state that a copy is available free of charge on request, and paragraph (j)(5)(i) carries the same requirement into the notice on review.

This determination rests on medical necessity or a similar clinical exclusion or limit, so please send the explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to this patient's circumstances. 29 CFR 2560.503-1(g)(1)(v)(B) and (j)(5)(ii) provide for that explanation free of charge on request.

Please identify every medical or vocational expert whose advice was obtained on behalf of the plan in connection with this determination, whether or not that advice was relied upon. 29 CFR 2560.503-1(h)(3)(iv) requires that identification for a group health plan.

This office intends to submit written comments, documents, records, and other information relating to this claim under 29 CFR 2560.503-1(h)(2)(ii). Please confirm the address for that submission and the date by which it must arrive.

For the record: paragraph (l)(1) provides that where a plan fails to establish or follow claims procedures consistent with 29 CFR 2560.503-1, the claimant is deemed to have exhausted the plan's administrative remedies and is entitled to pursue the remedies available under section 502(a) of ERISA.

Please send these materials in writing, and confirm in writing that this request was received and the date it was received. The plan's appeal deadline continues to run while this request is outstanding, so please treat it as time-sensitive and send the materials before that deadline. If any item is withheld, please say which item and on what basis.

Enclosures:
- Copy of the denial notice dated [DATE OF DENIAL NOTICE]
- Copy of the claim as submitted, with attachments
- ATTACH BEFORE SENDING: signed authorized-representative designation - the plan's own designation form where the plan publishes one

Sincerely,

[PROVIDER NAME, CREDENTIALS]
[PRACTICE NAME] - NPI [NPI] - Tax ID [TAX ID]

Before sending: read this letter against the denial notice and the patient's plan documents, replace every bracketed placeholder, and confirm the filing deadline and address printed on the notice itself.