SAMPLE - FICTIONAL DATA

October 27, 2026

Appeals Department, Sample Health Plan, PO Box 12345, Riverton, ST 12345

Subject: Appeal of denied claim CLM-7765301, member ID SHP-000-4417

Dear Sample Health Plan appeals team,

I am appealing the denial of claim CLM-7765301 for Maria Sample (Room and board, July 14, 2026). Your Explanation of Benefits dated October 15, 2026 denies it with remark code P31: “Prior authorization was not obtained for this service.”

This claim is part of my hospital stay for the birth of my child. My plan document says (page 2): “Medically necessary inpatient care for childbirth and delivery is covered.”

Please check my stay against this rule before asking for prior authorization. My plan document says (page 2): “Prior authorization is not required for a hospital stay for childbirth of up to 48 hours after a vaginal delivery or 96 hours after a cesarean section.”

If prior authorization could not be obtained in time, the plan does not allow a denial for that reason alone. My plan document says (page 2): “In emergency situations or when prior authorization cannot be obtained, covered services will not be denied solely for lack of prior authorization.”

Your Explanation of Benefits leaves $6,840.00 for me to pay on this claim. Please review the claim and process it as a covered service under my plan.

I am sending this appeal before April 13, 2027, within the time the plan allows after a denial. Please also send me free copies of all documents, records and other information relevant to my claim.

Federal rules for employer health plans give at least 180 days to appeal a denied claim (29 CFR 2560.503-1(h)(3)(i)).

Please send your decision in writing to the address below. Thank you.

Attached: Explanation of Benefits dated October 15, 2026; Member appeal form

Sincerely,

Maria Sample
12 Example Lane
Riverton, ST 12345
(555) 010-0199