Health & Managed Care

Health insurance claims correspondence is shaped by a dual regulatory framework: state insurance law and federal requirements under the ACA, ERISA, and CMS rules. Denial and appeal notices must meet specific content requirements that differ from P&C correspondence.

Key Characteristics

• Clinical Rationale: Adverse determinations must include the clinical or factual basis for the decision.
• Explainability: Strict adherence to the 5-part explainability structure (Decision, Facts, Provision, Rationale, Rights).
• Federal Overlays: ERISA and ACA requirements for internal and external appeal processes.
• Provider vs. Member: Correspondence may be directed to the member (insured) or the provider, depending on the nature of the dispute and assignment of benefits.

Key Correspondence Patterns

Adverse Benefit Determinations

• Denial notices — Must explain the specific reason for denial, the plan provision relied upon, and the clinical rationale if applicable.
• Appeal rights — Every denial must include notice of internal appeal rights and, where applicable, external review rights.
• EOB correspondence — Explanation of benefits linked to claim adjudication, showing what was paid, denied, and why.

Federal Overlay

• ACA requirements — Non-grandfathered health plans must comply with federal external review requirements.
• ERISA plans — Adverse benefit determinations must meet DOL content requirements: specific reasons, relevant plan provisions, appeal procedures, and availability of documents.
• CMS guidance — Medicare Advantage and Part D plans have separate notice requirements.

Provider Communications

• Prior authorization — Approval, denial, or partial-approval notices with clinical rationale.
• Payment disputes — Correspondence addressing reimbursement methodology, fee schedules, and coding disputes.

Medical Necessity & Out-of-Network

• Medical Necessity — Explanations for why certain procedures were or were not approved.
• Pre-authorization — Notifications for upcoming medical services.
• Out-of-Network — Notices regarding coverage limits and balance billing (No Surprises Act).

Common Errors

• Omitting external review rights in states that require them.
• Failing to include clinical rationale in medical-necessity denials.
• Not distinguishing between plan-level and insurer-level appeal rights.
• Using boilerplate language that does not cite the specific plan provision.