An out-of-network denial means your plan paid less, or nothing, because the provider was not in its network. You can appeal when no in-network provider was reasonably available to you (a network adequacy argument), or when emergency care, a valid referral, or continuity of care applies. This letter asks the plan to cover the claim at the in-network rate rather than as out-of-network. Under the Affordable Care Act, non-grandfathered plans generally allow at least 180 days from the date of the denial to file an internal appeal — but the controlling deadline is on your own denial letter, so check it first.
Before you appeal
- The denial letter or EOB with the exact reason and any code.
- Proof that no in-network provider was available within a reasonable time or distance: a list of in-network providers you contacted, their wait times or distances, or your plan’s own directory showing none nearby.
- Any referral or prior authorization that directed you to this provider.
- If this was emergency care, the records showing it was emergent.
- If you were mid-treatment when networks changed, records supporting continuity of care.
- Your member ID, group number, claim number, the date(s) of service, and the date of the denial.
The letter
[Your full name]
[Your address]
[City, State ZIP]
[Phone] | [Email]
[Date]
[Insurance company - Appeals Department]
[Address from your denial letter]
Re: Internal appeal of out-of-network denial - request in-network coverage
Member: [Name] Member ID: [number] Group #: [number]
Claim number: [number] Date(s) of service: [dates]
Denial date: [date] Denial reason/code: [as stated on the denial letter/EOB]
To the Appeals Department:
I am appealing the out-of-network denial of the claim identified above and
asking the plan to cover this service at the in-network benefit level and
in-network cost-sharing.
This care should be treated as in-network for the following reason(s):
[Choose what applies and give specifics. For example: No in-network provider
for [specialty/service] was available to me within a reasonable time or
distance, so I had to use an out-of-network provider. I contacted the
in-network providers listed by the plan and they were [not accepting patients
/ too far away / unavailable within a clinically appropriate time], as shown
in the enclosed records. OR: This was emergency care. OR: I was referred to
this provider on [date]. OR: I was already under this provider's care for an
ongoing condition when the network changed (continuity of care).]
Because an adequate in-network option was not reasonably available, applying
out-of-network cost-sharing is not appropriate, and I ask the plan to process
this claim at the in-network rate.
Enclosed in support:
- Copy of the denial letter / EOB
- List of in-network providers contacted, with dates and outcomes
- Referral or prior authorization, if applicable
- Records showing emergency or continuity-of-care circumstances, if applicable
Please send me a written decision within the timeframe required for my plan.
If the denial is upheld, please send the specific plan provisions you relied
on and tell me how to request an external (independent) review.
Thank you,
[Your signature]
[Your printed name]
How to send it
File within your plan’s appeal deadline — the date is on your denial letter (ACA plans generally allow at least 180 days). Send by certified mail with return receipt requested, or use the plan’s official appeals portal, fax, or member-services address, and keep a dated copy of everything. If a delay could seriously harm your health, ask for an expedited (urgent) appeal, which is decided much faster.
Notes. Network adequacy standards vary by plan type and state, so frame the appeal around the facts: that no in-network provider was reasonably available within an appropriate time or distance. Separately, the federal No Surprises Act protects many patients from surprise out-of-network balance bills for emergency care and for care at in-network facilities, but that is a billing dispute handled through a different process; this letter focuses on getting the claim itself covered at in-network cost-sharing. See also the internal appeal letter, the medical-necessity appeal if necessity is also cited, and the external review request if your internal appeal is upheld. This is general information, not legal, medical, or insurance advice.