Should I attach my EOB, medical records, or both

Different denials call for different enclosures. Sending too little makes the letter look thin. Sending too much slows the appeal down and can give the plan reasons to send it back for review. Here is the rule of thumb for each denial category.

Always attach

• A copy of the denial letter or EOB. This is the document the plan sent you showing the denial. It has the claim number, date of service, and denial reason. Every appeal needs it.

Attach for medical-necessity denials (CO-50)

• The prescribing or ordering doctor's notes for the visit that led to the treatment
• The doctor's letter of medical necessity, if you can get one written (usually 1 to 2 paragraphs)
• Any prior treatment records showing the medical history that supports the current claim
• Relevant test results (labs, imaging reports)

Do not attach:

• Your entire medical chart back to childhood
• Records unrelated to the condition at issue
• Records from other providers unless they bear on the specific care being denied

Attach for prior-authorization denials (CO-197)

• Evidence that you or the provider did request prior authorization (portal screenshot with timestamp, phone call log with reference number, or approval letter if you have one)
• The denial letter
• If the care was urgent enough to skip prior authorization, evidence of the emergency (ED admission record, chart note)

Attach for out-of-network or "not covered" denials (CO-96, PR-96)

• The denial letter
• The section of your plan document that either (a) covers the service, or (b) creates an exception the plan should have honored (network-adequacy failure, no in-network provider available within a reasonable distance)
• If network-adequacy: a printout of the plan's own provider directory showing no in-network option in your area

Attach for missing-information denials (CO-16)

• The denial letter
• The information the plan says was missing (or evidence that the provider sent it)
• Provider's remittance advice showing they submitted the claim with the required data

Attach for bundling denials (CO-97)

• The denial letter
• The provider's operative note or procedure note showing the two services were distinct
• CMS modifier guidance (your provider can supply the specific modifier)

What to leave out

• Marketing materials from the insurer
• Copies of premium checks
• Testimonials from friends or family
• Anything with information about other patients (privacy issue)
• Anything longer than 15 pages total unless the denial is a complex medical-necessity case

How to organize the packet

1. Cover letter (your appeal, signed)
2. Denial letter or EOB
3. Enclosures, in the order the appeal references them
4. A short index at the end of the appeal listing what is enclosed

Paper-clip the whole packet. Do not staple.

What if you do not have the records

If you need medical records from your provider, request them in writing. Under HIPAA (45 CFR 164.524), your provider must give you records within 30 days. Many will send them within a week if you ask nicely and pay the (usually small) copying fee.

If unsure

Ask support. Include your appeal ID and a photo of what you were planning to attach, and we will tell you whether it strengthens or clutters the packet.