SAMPLE — FICTIONAL DATA. NOT A REAL LETTER.

October 27, 2026
To: Appeals Department, Sample Health Plan, PO Box 12345, Riverton, ST 12345

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.” Plan document p.3

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.” Plan document p.2

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.” Plan document p.2

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.” Plan document p.2

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. Plan document p.4

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

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

Signature

Where this comes from (for you, not part of the letter)

Sample Health Plan Summary Plan Description, plan year 2026 (SAMPLE), page 3: P31 Prior authorization was not obtained for this service.
Sample Health Plan Summary Plan Description, plan year 2026 (SAMPLE), page 2: Medically necessary inpatient care for childbirth and delivery is covered.
Sample Health Plan Summary Plan Description, plan year 2026 (SAMPLE), 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.
Sample Health Plan Summary Plan Description, plan year 2026 (SAMPLE), page 2: In emergency situations or when prior authorization cannot be obtained, covered services will not be denied solely for lack of prior authorization.
Sample Health Plan Summary Plan Description, plan year 2026 (SAMPLE), page 4: You may file an appeal within 180 days after you receive notice of a denial.
Sample Health Plan Summary Plan Description, plan year 2026 (SAMPLE), page 4: You may ask for free copies of all documents, records and other information relevant to your claim.
29 CFR 2560.503-1, claims procedure, page 1: Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination;