Your insurer refused to pay for care, or refused to approve it in advance, and you want to appeal.
Each step builds on the one before it, so order matters. You do not have to finish in one sitting — the assistant can pick up where you left off if you tell it what you already did. Expect several hours across several days, not minutes.
Tells the assistant how to behave: no invented facts, no guessing, quote things exactly.
You are helping me appeal health-insurance adverse determinations. Non-negotiable: 1. DEADLINES FIRST. Before drafting anything, compute every appeal window from the letters and show me the board. If a deadline is near, we file a timely rights-preserving appeal now and supplement later. 2. Never state a fact without a document or logged call behind it. A letter proves only what it says; quote it verbatim. 3. You do not practice medicine. Medical-necessity statements come from my clinicians, in their words. Your job is to hand them the plan's actual criteria and assemble the record around their letter. 4. Identify my plan type (ERISA self-funded / fully-insured / Medicare Advantage / Medicaid managed care) from my documents before citing any appeal right, and tell me your confidence and basis. 5. Every count and date in any output is computed from the catalogue with an assertion that fails on mismatch. 6. Keep an append-only decisions file recording every ruling I make. 7. This is high-stakes: when something needs a lawyer, a broker, or my state's consumer-assistance program, say so plainly.
Letters, EOBs, portal downloads, bills — with the decisive line quoted.
Inventory every document in my insurance dispute. Sources: my insurer portal downloads (EOBs, letters), mail scans, my provider portal (claims, orders, notes I already have), email, and my call notes. For each item: date on the document, date received (if different — envelopes matter for deadlines), type (EOB / denial letter / prior-auth determination / appeal acknowledgment / plan document / SPD / physician letter / bill), the claim number(s) and service dates it references, and one factual sentence on what it says — with the decisive line quoted verbatim. Also build the call log from whatever exists (notes, phone screenshots, portal message threads): date, time, representative name, reference number, what was said — only what my contemporaneous notes actually record. Flag calls I mention from memory with no note as unverified. Rules: - Never rename originals. Output a manifest I can review. - Flag every document whose received-date is unknown — those create deadline ambiguity we must resolve conservatively (prompt 02). - Flag any EOB row where the denial code on the EOB differs from the reason in the letter — that mismatch is evidence. - List what is MISSING: no SPD/plan document on file? No letter for a denial that appears on an EOB? Missing items become the first requests we send.
Get the plan document/SPD if you don't have it — request it in writing from the plan administrator (ERISA plans owe it to you on request). Everything later quotes it.
What kind of plan you have, and exactly how many days you have left.
From the inventory, do two things before anything else: **A. Determine what governs my plan.** From my ID card, EOBs, SPD, and the denial letters' appeal-rights language: is this an employer self-funded plan (ERISA), a fully-insured employer or individual plan (state insurance law), a Medicare Advantage plan, or Medicaid managed care? State your confidence and exactly which document line supports it. If uncertain, list what to check (e.g. asking HR whether the plan is self-funded). Do not cite any appeal right until this is settled. **B. Build the deadline board.** For every adverse determination: date of the letter, date received (use the conservative earlier-trigger reading when unknown), the applicable appeal window under the machinery from (A), the computed due date, days remaining, and the expedited path if care is ongoing. Compute dates in code and assert them; show your arithmetic. Sort by urgency. If anything is due within 21 days: stop, and draft a short rights-preserving appeal for that item NOW — one page: what is appealed, that I contest the determination, that supporting documentation follows, and a request for the complete claim file. Polishing comes after the clock is safe.
Put the due dates in your own calendar with two reminders each. The board is regenerated whenever a new letter arrives — every new determination starts a new clock.
Pull apart the denial letter and find what standard they actually applied.
Dissect every adverse determination into the denial ledger. One row per determination: date · claim/auth number · service and provider · what exactly was denied · the insurer's stated reason QUOTED VERBATIM · the plan provision or clinical criteria they cite (name and section, verbatim) · the reviewer identified (name/credential if stated; note if none is given) · appeal rights as stated · current status. Then classify each denial into its family, because the fight differs: - NOT MEDICALLY NECESSARY → fought with the plan's own criteria + treating physician's point-by-point statement (prompt 05). - EXPERIMENTAL / INVESTIGATIONAL → fought with the plan's definition, coverage policy versions, and published evidence the physician cites. - NO PRIOR AUTH / OUT-OF-NETWORK → fought with process facts: who called whom when, network directory entries at date of service, referral paperwork. - CODING / ADMINISTRATIVE → often not an appeal at all: the provider's billing office refiles corrected claims. Draft the message asking them to, and track it. - ELIGIBILITY / COORDINATION OF BENEFITS → document-driven; list exactly which document resolves it. Flag every anatomy defect in their letters: a reason stated in boilerplate that doesn't reference my facts, criteria cited but not provided, no reviewer credential disclosed, appeal-rights language missing or inconsistent with the plan type. Each defect goes in the record — factually, without adjectives.
The ledger's "their stated reason, verbatim" column is the spine of every appeal letter — the appeal answers exactly what they said, not what we assume they meant.
The claim file shows how the decision was made. Request it before appealing.
Draft a written request to the plan for the complete claim file for each adverse determination, addressed per the denial letter's instructions, stating that following an adverse benefit determination I request, free of charge, copies of all documents, records, and information relevant to the claim, including: the complete claim record and internal notes; the specific internal rules, guidelines, protocols, or clinical criteria relied upon; the identity, qualifications, and specialty of every reviewer; any expert opinions obtained whether or not relied upon; and, where calls are referenced, the call recordings or logs. Keep it one page, factual, with claim numbers and dates in a table. Generate one per determination or one consolidated letter as appropriate. Include the certified-mail / fax / portal-upload delivery plan (prompt 10 discipline) and a diary date to follow up if no response. When the file arrives: compare what the reviewer relied on against (a) the plan document's actual criteria and (b) my physician's records. Produce a gap list — criteria misquoted, records missing from their file, reviewer specialty mismatched to the service, timestamps inconsistent with a real review. Each gap becomes a numbered point in the appeal.
The packet: what you are appealing, why, and every document that proves it.
Assemble the appeal for <determination> from the bundle:
1. **The appeal letter** (2–4 pages, factual, no pleading):
- Header: member/claim/auth numbers, service, provider, dates, "APPEAL of
the <date> adverse determination" — and if the window is tight, the
timely-filing sentence up front.
- What they said: their stated reason and cited criteria, quoted verbatim.
- What the plan's own documents say: the coverage language and criteria,
quoted, with section numbers.
- What the record shows: the process facts in order — referrals, calls
(with reference numbers), submissions, their file's gaps (from prompt 04).
- What is attached: the treating physician's statement and each exhibit,
numbered.
- The ask: reverse the determination and pay/authorize; respond within the
required period; and (again) produce the claim file if not yet provided.
2. **The physician statement scaffold** — for my clinician, not from them: the
plan's actual criteria, point by point, with space for their clinical
judgment against each. I hand this to the physician's office; the words
must be theirs.
3. **Exhibit set** — numbered, each referenced at least once in the letter.
Same discipline as ever: each exhibit is what it is; captions state only
what the document shows.
Assert: every date in the letter appears in the bundle; every criterion quoted
matches the plan document character-for-character; the letter cites every
exhibit; total page count.If the plan offers two internal levels, plan to use both. Every response letter they send goes into the bundle and gets its own anatomy row.
If the internal appeal fails, an independent reviewer can overturn them.
Prepare the external-review submission for <determination>: - The request form/letter per my jurisdiction's process (identify it from the final denial letter's language and my state's insurance department site; cite where you found the procedure). - The complete package an independent physician reviewer needs to say yes in one reading: the denial ledger row, the internal appeal letter and their responses, the physician statement, the claim-file gap list, and exhibits — with a one-page cover chronology on top. - Deadline check: external-review windows run from the final internal denial; compute and assert mine. - If care is ongoing/urgent: the expedited external review path instead, with the physician certification it requires. The IRO reviewer is the first genuinely independent clinician to read the file. Write the cover chronology for a smart stranger with 30 minutes: dates, facts, criteria, no adjectives.
Who oversees your plan, and what they can actually do.
From the same bundle, generate the regulator complaint appropriate to my plan type: state Department of Insurance consumer complaint (fully-insured/ individual), DOL Employee Benefits Security Administration inquiry (ERISA self-funded), 1-800-MEDICARE / CMS complaint (Medicare Advantage), or the state Medicaid ombudsman. Contents: the one-page chronology, the denial ledger, the specific conduct complained of stated factually (missed decision deadlines, criteria not provided on request, reviewer credential absent, claim file not produced, boilerplate reasons), what I am asking the regulator to do, and the exhibit set. No adjectives; regulators read patterns, and a file that looks like a docket gets treated like one. Also tell me honestly what a complaint does and doesn't do in my situation: it creates a docketed record, insurers must respond to it, and pattern complaints drive market-conduct exams — but it is not itself an order to pay.
Have the assistant argue the insurer's side, then fix what it finds.
Attack my complete appeal package from five perspectives, with specific findings and locations: 1. **The plan's appeals nurse-reviewer** who wants a defensible yes: what's missing that would let you approve this in one pass? 2. **The plan's counsel** who wants the denial to stick: every date error, every criteria quote that isn't exact, every claim in my letter that a document doesn't back, every process assertion my own call log doesn't support. What's your best paragraph against me? 3. **The IRO physician reviewer**: is the clinical story assembled for a 30-minute independent read? Where does the packet make you hunt? 4. **The regulator's intake analyst**: does the complaint read as a pattern of conduct, or as an unhappy customer? What would make you open a file? 5. **Another patient using this as a template**: what here is specific to my case but disguised as method? What would mislead them? Consolidate into fixes-now / decisions-for-me / risks-accepted, apply the fixes, and record the rest in the decisions file.
One PDF, properly indexed, ready to send.
--- Generate the master PDF from the bundle: cover chronology (one page), the deadline board, the denial ledger, each appeal/response in order, the claim-file gap list, exhibits with a numbered index. Every number asserted at build; filename carries the month and year. This is the file a lawyer, a regulator, or a state consumer-assistance program can pick up cold. A password-gated evidence site (see `site/` — same kit as the sibling repos) is worth building only for long multi-denial sagas with many documents and parties: it gives reviewers one-click access to full documents and gives you an access log. For a single denial, the PDF packet is the right tool — don't build infrastructure the dispute doesn't need. If a site is warranted: PHI discipline is stricter than PII. Nothing goes online beyond what the dispute requires; strip EXIF; the reviewer credential goes only to named case handlers; rotate credentials when the matter closes.
Delivery proof and a record of every response.
For every outbound submission, record in the bundle: what was sent (hash the PDF), to whom, by which channel, and the proof — certified-mail tracking, fax confirmation page, portal submission screenshot with timestamp and confirmation number. Their decision clocks run from receipt; my proof of receipt is what makes a missed clock a fact rather than a suspicion. Maintain the outcome ledger: each determination → appeal filed (date, proof) → their response due date → their actual response date → outcome → next rung. Flag every blown deadline on THEIR side; under most machinery a plan that misses its decision deadline has exhausted the process for me, unlocking the next rung early — note where that applies to my plan type. Diary cadence: confirm delivery within 3 days of each send; check for a response at the halfway mark and at the due date; regenerate the deadline board on every inbound letter.
There is a complete demonstration case file — made up, but the real shape of the result.