Washington state Office of the Insurance Commissioner
Letter template to request a second-level (external) review
[Personalize this letter as needed, especially the information in brackets]
[Your name]
[Your address]
[Date]
[Address of your health plan’s appeal department]
Re: [Name of the insured]
Plan ID number: [Your plan ID number]
Claim number: [Your claim number]
To whom it may concern:
I’m requesting an external review by an independent review organization (IRO) of the final internal adverse benefit determination I received on [date], which is included with this appeal.
I filed my internal appeal on [date], in response to [for example, a procedure I received at the advice of my primary care doctor, which you did not consider to be medically necessary]. Your review board returned their ruling, upholding the original decision to not cover this claim.
[Include any new relevant information, if any, that has come up since you filed your first appeal. Keep it factual and to the point.]
I look forward to your direct response as soon as possible.
Sincerely,
[Your name]
[Your address and phone number]
................
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