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Health Insurance Claim Denied? See What Insurers Said Behind the Scenes
Learn how to request your health insurance claim file, which can include details about what your insurer is saying about you and your case.
When a health insurance company is deciding whether to pay for your medical treatment, the company generates a file around your claim. All the records associated with your case should be part of your file. This includes documents explaining the reasons your claim was denied.
You have a right to see this file. Federal regulations require most health insurance plans to give people an opportunity to review documents related to their claim for free. So if your insurer talks to your doctor, if a nurse takes notes, or if two people speak about it on the phone, all of those records should be available to you.
“It’s a treasure trove of information,” said Juliette Forstenzer Espinosa, a health lawyer and senior lecturer of health policy at George Washington University. “But most people have no idea how to get it.”
Health insurers rarely advertise that people can access their claim files, Espinosa said. Where guidance exists, it is often embedded deep in denial letters. Few offer templates or even give instructions on their websites.
Patients who make it through the records request process get information that can be revelatory. Some told us they received case notes exposing how they had been funneled into programs the health insurance company deployed to cut costs. A few obtained audio recordings of phone calls showing company staff introducing errors into their cases.
And others, such as former Cigna patient Lee Mazurek, found out exactly how much companies projected saving on their cases. Mazurek had been on a treatment regimen for nearly nine years that was keeping his Crohn’s disease at bay. Changing it, a Cigna employee estimated, could save more than $98,000. (Cigna spokesperson Justine Sessions said the insurer only suggests changes when clinically appropriate and that cost is never the sole determining factor. She said Cigna does not directly benefit from such savings.)
Taken together, these documents can offer a window into the opaque system of health insurance denials. Details in them have helped us report on some of the country’s largest insurance companies and their attempts to cut costs at the expense of patient well-being.
We have spoken with patients, health care providers, former and current health insurance employees and health policy experts to better understand how people facing denials can request their information. We believe it is important to share with our readers what we are learning about this process. To that end, we have collected advice on requesting your claim file and answers to common questions you may have, including a template you can use to get your request started.
If you end up requesting and obtaining your claim file, you can share it with ProPublica reporters by filling out this form. These documents help us better understand the systems behind claim denials and can fuel our future reporting.
If you send over your claim file, ProPublica reporters will be the only ones reading the files. We appreciate you sharing your information and we take your privacy seriously. We are gathering these for the purposes of our reporting, and will contact you if we wish to publish any part of your story. If you wish for additional anonymity, we have set up encrypted tiplines for extra security, including Signal and postal mail (address to ATTN: Maya Miller). If you have any questions, you can email healthinsurance@propublica.org to get in touch.
Since we are journalists and not lawyers, we are unable to provide any legal advice about this process.
What’s the difference between a health insurance claim file request and an appeal?
After you receive a denial, you can submit an appeal. This means you are asking the health insurance company to reconsider its decision.
When you submit a claim file request, you are asking the insurer to send you all of the records generated around your claim. Patients and lawyers said they found it helpful to submit these requests before an appeal.
Which health insurance plans can I request a claim file from? Is mine included?
You have the right to request your claim file if you:
Have insurance through your employer.
Have a private plan that is not through your employer (known as an individual nongroup plan). Travel insurance plans are not eligible.
Are under a state or local government plan.
Similar rights apply to people under Medicaid plans.
I want to get my health insurance claim file. Where do I start? Is there a form?
A few insurers (namely, Cigna and Elevance Health) offer request forms that you can download and fill out, but most do not.
Here’s a template of a claim file request that you can fill out no matter what health insurance plan you have. It is adapted from one created by Health Law Advocates, a public interest law firm based in Boston that provides free legal services to people struggling to access health care. The template includes:
A list of all of the records that should be included in your claim file.
Space for you to write in your case details.
If you use one of the forms provided by an insurer, do not hesitate to add pages. Insurers may not provide enough space for all the language that can be helpful, according to patients and lawyers who regularly submit requests.
You will likely need to print the request out. If you do not have access to a printer you can visit your local public library, which should have one available for you to use.
What information do I need to provide as part of my request?
Always make sure to include your name, address and phone number, plus the date you are sending the request.
You will likely need:
Your Plan ID and unique Member ID (often listed directly below your name on your health insurance card).
The unique case number(s) associated with your denied claim. This will allow you to ask for specific records associated with the case number(s). Health insurance plans may instead call this your service reference number or have another name for it altogether. You can often find this number on the first page of a denial letter or of a letter from your health plan explaining how much you must pay for the treatment or service (known as an explanation of benefits).
The dollar amount of the claim.
The dates of your appointments, procedures or other services in question.
The date you received notice of the denial.
Can’t find one of these? Don’t stress. You can either call your insurance company’s member service line or request it from your health care provider.
If you end up calling your health insurance plan’s member service line, patients and lawyers have suggested recording the call or taking written notes so you have proof of the interaction. If you want to record the call, be sure to ask the person on the other line for permission to do so.
How do people usually word these requests?
Whether you use a health insurance plan’s request form or write your own claim file request from scratch, you may want to consider asking for:
Case management information
Medical utilization information
Telephone logs and call summaries
Recordings of telephone conversations
Any other correspondence
Any medical records and assessments
All other records related to your unique claim number(s)
Example of a claim request submitted by former Cigna member Lee Mazurek. After submitting the request, Mazurek received a 55-page packet from the health plan that helped reveal why his claim was denied.Credit:Courtesy of Lee Mazurek
If you are writing up your own claim file request from scratch, you may also want to include a line saying this is a request for a claim file, not an appeal. (Health insurance plans have mistaken claim file requests for appeals.)
What should I actually send to the health insurance plan?
Along with the printout of your claim file request form, patients and legal experts say, it is helpful to send a copy of the denial letter, or the letter the insurance plan sent you explaining how much you owe for the treatment or service. (Patients and their advocates stressed that you should send in a copy, rather than the original denial letter you received.)
You might also want to keep a copy of the claim file request for your records.