Expedited/Urgent Appeal Letter Template

Letter Template: Expedited Appeal

* EXPEDITED APPEAL — URGENT *
[Your Name]
[Your Address]
[City, State ZIP]
[Date]
[Insurance Company Name]
[Appeals Department] — EXPEDITED
[Address]
[Fax Number]
Re: EXPEDITED APPEAL — Urgent Medical Need
Member Name: [Your Name]
Member ID: [Your ID Number]
Claim/Reference Number: [Number]
Denied Treatment: [Treatment]
Dear Appeals Review Committee:
I am filing an EXPEDITED APPEAL pursuant to [29 CFR
§2590.715-2719 / your state statute] because a standard
appeal timeline would seriously jeopardize my life, health,
or ability to regain maximum function.
URGENCY STATEMENT
[Explain why waiting for standard timelines would be harmful:
Active disease progression
Severe pain not adequately managed
Time-sensitive treatment window
Risk of permanent harm without treatment]
TREATING PHYSICIAN STATEMENT
Dr. [Name], my treating [specialty], has determined that
any delay in [treatment] poses a serious risk to my health
because [medical reason]. [Dr. Name's office has also
contacted your medical director by phone on [date] to
request expedited review.]

CLINICAL JUSTIFICATION
[Brief clinical argument for the treatment]
I request that this appeal be processed on an expedited
basis with a decision within 72 hours as required by federal
law. A delay in treatment would [specific harm].
Sincerely,
[Your Name]
Enclosures:
Physician urgency letter
[Medical records]

Critical Steps

1. Fax AND mail the letter (fax for speed, mail for record)
2. Have your doctor call the insurer simultaneously
3. Mark URGENT/EXPEDITED prominently on all correspondence
4. Follow up within 24 hours if no response
5. File with your state commissioner simultaneously for additional pressure