Guides · Any · Claim file request
How to Request Your Claim File and Denial Criteria From Your Insurer
Ask for the documents and guidelines behind your denial, free of charge. Sample request included.
Under federal claims rules for employer and ACA plans, you can generally request free copies of documents relevant to your claim, including the clinical criteria or guidelines used. Knowing the exact criteria makes your appeal far more targeted.
Free sample appeal paragraph
I request, free of charge, copies of all documents, records and other information relevant to my claim [number], including the complete claim file, the clinical criteria, guidelines or protocols relied upon, and the names and qualifications of any medical reviewers consulted.
Replace the [brackets] with your details. This is a starting point, not legal advice.
What to do
- Send the request in writing and keep a copy.
- Ask early, while you still have time to use the criteria.
- Still file your appeal on time even if documents are slow to arrive.
Check your denial free
Enter your denial details for a free analysis of the likely denial type, appeal options and grounds. If you want, get a full tailored appeal letter PDF with checklist and deadlines for $4.99.
Start the free checkFrequently asked questions
Do I have to pay for my claim file?
For employer and ACA plans, relevant documents are generally available free on request.
What if they don't send it?
Note it in your appeal and consider contacting your state insurance department or the U.S. Department of Labor (for employer plans).
How do I appeal a claim file request denial?
Start with the instructions and deadline on your denial letter. Gather your medical records and a letter of medical necessity, respond directly to the stated denial reason, and file an internal appeal. Keep proof of submission.
Is external review available?
For many non-grandfathered plans, independent external review may be available for denials involving medical judgment after a final internal denial, generally within 4 months. Confirm on your denial notice.
Related guides
- ACA Internal Appeal Deadlines Explained
- ACA External Review: How It Works
- Medicare Advantage Organization Determination Appeals
- How to Appeal a Medicaid Denial (Plan Appeal and State Fair Hearing)
- How to Appeal a Medicare Part D Drug Denial
- How to Appeal an Employer Health Plan Denial (ERISA Plans)
- All appeal guides
Document preparation / educational use only. This site is not a law firm, regulator, airline, insurer, or parking operator. Nothing here is legal advice. Outcomes are never guaranteed. Review every letter carefully before sending and consult a licensed professional if you need advice about your situation.