Tracking Sheet: Appealing a Denial of Service
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
| Action | Date | Contact Person (Provider/insurer etc) | Phone number | Deadline for next steps | Copies made | Notes |
|---|---|---|---|---|---|---|
| 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/Affiliation | Date | Phone Number | Notes |
|---|---|---|---|
Posted on: June 15, 2012
Page Last Modified:
09/10/2024 06:11 PM