The Center for Consumer Information & Insurance Oversight

Tracking Sheet: Appealing a Denial of Service

Claims Number and Description: 

Name of Provider: 

Check one: 

□ Claim is for prior authorization 

□ Claim is for treatment/service provided


ActionDateContact Person (Provider/insurer etc)Phone numberDeadline for next stepsCopies madeNotes
I submitted a claim to my health plan.       
My health plan denied all or part of the claim.      
I sent my insurer a letter or form authorizing my doctor or someone else to file my internal appeal for me (if necessary)      
I, or someone I chose to act for me, sent my plan notice that I am appealing its decision. (Or, if my case was urgent, I told my plan, verbally.)      
I sent my plan additional documents (if necessary)      
My plan denied my internal appeal      
I filed a 2nd appeal with my group health plan (if required)      
My plan denied my 2nd appeal      
My plan provided me with copies of the evidence and explanations it used to make its decision.      
I requested an external review      
I sent this request to the appropriate agency      
The external reviewer decided whether to uphold or overturn my plan’s denial of my claim for benefits.      

Record of additional phone conversations and correspondence

Name/AffiliationDatePhone NumberNotes


Posted on: June 15, 2012