Purpose
An appeal response letter communicates the outcome of an internal appeal or reconsideration of a previously denied claim. Whether the appeal is upheld (denial affirmed), overturned (denial reversed), or partially modified, the letter must explain the decision, the basis for it, and any further options available to the claimant.
When to Send
The appeal response must be sent within the timeframe required by the applicable jurisdiction or, for ERISA-governed plans, within the DOL-mandated deadlines. For health claims, this is typically 30 days for pre-service appeals and 60 days for post-service appeals.
Required Components
Appeal Decision
State clearly whether the denial is upheld, reversed, or modified. Do not bury the result in the middle of the letter.
Basis for Decision
If the denial is upheld, explain:
- What new information was reviewed (if any)
- What the appeal review determined and why
- The specific policy provisions or plan terms that support the decision
- Any clinical rationale if the denial involved medical necessity
If the denial is reversed, explain what changed and what the claimant can expect next.
Additional Review Rights
If the denial is upheld, explain:
- Whether additional levels of internal appeal are available
- External review rights (for health claims subject to ACA/ERISA)
- State Department of Insurance complaint process
- Right to bring a civil action (for ERISA plans)
- Appraisal or arbitration rights (for property/casualty)
Reviewed Materials
List the materials considered during the appeal, including any new documentation submitted by the claimant.
Jurisdiction Notes
Health / ERISA
DOL regulations require that the appeal response include: the specific reasons for the decision, references to plan provisions, a statement of the claimant's right to receive the claim file, and notice of the right to bring a civil action under ERISA Section 502(a).
Property & Casualty
For P&C claims, the appeal response should reference the appraisal clause if the dispute is over valuation and explain the external complaint process through the state DOI.
Adjuster Guidance
- Ensure the appeal was reviewed by someone who did not participate in the original denial decision
- Address each argument raised in the appeal specifically
- If new information was submitted, explain how it was considered
- Do not use identical language from the original denial — the appeal response should demonstrate fresh review