A prior authorization (PA) denial usually means the plan’s process step was not met — not that your treatment is medically wrong for you. This letter argues that authorization was actually obtained, that the service was exempt or urgent, or that the plan failed to respond in time, and asks the plan to reconsider and approve. Under the Affordable Care Act, non-grandfathered plans generally allow at least 180 days from 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 code.
- The ordering provider’s order or referral for the service.
- Any authorization reference number, approval date, or call notes if auth was requested.
- Proof of timing — when the PA request was submitted and when the plan responded (or did not).
- Notes on whether the service was urgent, emergent, or exempt from PA under your plan.
- Your plan’s PA rules from your plan documents (which services need PA and the response deadlines).
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 prior authorization denial
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 prior authorization denial above and ask the plan to
overturn it and authorize the service ordered by my provider.
A prior authorization denial is a coverage and process decision, not a
medical judgment about whether this treatment is right for me. The service
was ordered by [ordering provider name and specialty] for treatment of
[diagnosis].
The denial should be reversed for the following reason(s) [keep what applies]:
- Authorization was obtained. It was requested on [date] and approved under
reference number [number]. The enclosed records confirm this.
- The service did not require prior authorization, or was exempt, because
[urgent / emergent / covered exception under the plan].
- The plan did not respond to the authorization request within the required
timeframe. The request was submitted on [date] and no timely decision was
issued.
So that I can respond fully, please send me in writing the prior
authorization rules and timing requirements the plan applied, and the
credentials of the reviewer who made this decision.
I request reconsideration of the authorization and a peer-to-peer review
between my ordering provider and the plan's reviewing physician.
Enclosed in support:
- Copy of the denial letter / EOB
- The ordering provider's order or referral
- Authorization request records / reference number (if available)
- Documentation of submission and response timing (if available)
Please send me a written decision by the plan's required timeframe. If the
denial is upheld, please send the information I need to take the next step.
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). Use certified mail with return receipt, or your plan’s official appeals channel (fax, portal, or member-services address), and keep a dated copy. If you have not yet had the service and a delay could harm your health, ask for an expedited appeal and request a peer-to-peer review so your provider can speak directly with the plan’s reviewer.
Notes. Under the ACA internal-claims and appeals rules (29 CFR 2590.715-2719), plans must decide pre-service claims and appeals within set timeframes (generally 30 days for non-urgent pre-service appeals, and 72 hours for urgent care), and must give you, on request, the rules and criteria used. If your treatment was ordered because it is the right care for you, also see appeal a ‘not medically necessary’ denial. See also request a peer-to-peer review, expedited / urgent appeal, and the internal appeal letter. This is general information, not legal or medical advice.