Your insurance claim file contains all the documents, criteria, and reviewer notes used to deny your claim. You have a legal right to this information, and it's essential for building a strong appeal.
Your Right to the Claim File
Under federal law (ACA and ERISA), you have the right to access all documents used in making the denial decision, including:
What's in the Claim File
- Clinical criteria — the specific guidelines applied to your case
- Medical director notes — the reviewing physician's analysis
- Nurse reviewer notes — initial clinical review documentation
- Benefit plan provisions — the policy sections cited in the denial
- Medical records received — what your insurer actually reviewed
- Prior authorization requests — including any incomplete submissions
- Phone call notes — records of conversations with your provider
How to Request
- Submit a written request to your insurer's member services or appeals department
- Reference your legal right — cite ERISA Section 503 for employer plans or ACA for individual/marketplace plans
- Be specific — request ALL documents, records, and criteria related to your claim
- Allow 30 days — insurers must respond within a reasonable timeframe
- Follow up if you don't receive a response
How to Use the Claim File
- Compare criteria to your records — identify gaps between what's required and what was submitted
- Check what records were reviewed — your insurer may not have seen all relevant records
- Review reviewer qualifications — was the reviewer qualified in the relevant specialty?
- Identify errors — wrong diagnosis, missing records, or misapplied criteria