Start here
The free tool below runs entirely in this browser — no account, nothing stored or transmitted. Redact anything you would not want kept before you type it.
Open the companion tool →Why criteria convert a denial into a checklist
A criterion can be met with documentation. A conclusion cannot. The request moves the argument from opinion to evidence.
Write it as a document-provision demand with the claim reference attached, asking for the criteria, the evidence standard, and whether an automated tool contributed to the decision.
The protocol
- Collect the denial letter, claim number, and the dates of service.
- Ask in writing for the specific criteria and evidence standard applied.
- Ask whether an automated system was used and who reviewed the decision.
- Request the specific records the plan says are missing, if any.
- Respond to the criteria directly, attaching clinician documentation, and diarize the appeal.
What the tool does
Build a claim-denial criteria request It runs locally in this browser and sends nothing.
Limit first: This is a preparation aid, not medical, legal or insurance advice. It cannot force a payer to pay, guarantee an appeal outcome, or tell you which care is right for you.
Open the companion tool →Cost and free path
Cost: Free: one complete run in this browser, no account. Optional $4 one-time unlock allows unlimited runs of this tool on this browser. The free path and safety guidance never require payment.
Rule status (mixed route): Status, 2026-10-03: specific-reason and criteria requirements are operative for impacted plans; HHS OIG found denial explanations frequently failed to meet coverage rules, which is the gap this written request is aimed at.
Automated decision this documents: automated claim adjudication and medical-necessity criteria
Free path, in order (no cost):
- The plan's appeals address on the denial letter — filing is free
- Your state insurance department consumer service
- A legal-aid health unit or patient advocate through LawHelp.org
What this cannot do: It cannot force a payer to pay, guarantee an appeal outcome, or tell you which care is right for you.
Sources checked 2026-10-03 · source bank reviewed against the live pages listed in metadata.
One human next step
Send the request to the plan's appeals address and copy your state insurance department if the plan does not answer within its own stated window.
Research log and safety checks
AI-assist path: not used for a verdict. This builder organises the reader's own documents and names an independent source; it does not infer authenticity, eligibility, or legal rights. §6.9/§6.10/§6.11 disclosed in the batch report; §6.12 status line carried in metadata as `status_line`.
§0.5 protection result: category is insurance-and-medical-costs; crisis-adjacent: no; fear/urgency/scarcity toolkit used: no. The protective function is free and the paid feature is convenience only.