What if my insurer requests more information
Getting a "we need more information" letter is not a denial. It is a common step. Plans send them when the reviewer thinks there is a gap in the record. Handle it correctly and it can turn into a reversal.
Read the letter carefully
The letter should tell you:
- Exactly what information they want
- Where to send it
- The deadline
For ERISA plans, 29 CFR 2560.503-1(f)(3) says the plan can ask for more information but the clock is tolled (paused) only while it waits, and it must give you at least 45 days to respond. For Medicare Advantage, 42 CFR 422.590 has similar tolling rules.
Do not miss the deadline
If you miss the deadline, the plan can decide the appeal on the record without your submission. That is usually a denial. Set a calendar reminder for two days before the deadline.
Respond in writing
- Do not respond by phone. Even a "helpful" phone call is not part of the appeal record
- Respond by the method the plan specified. If it says fax, fax. If it says mail, mail
- Send certified with return receipt if you can
- Keep a copy for your file
- Reference the appeal by name, member ID, and the plan's own request letter date
Sample response opening
"Regarding my appeal of claim [claim number] for [member name], I received your letter dated [date] requesting [describe request]. In response, please find enclosed [list what you are sending]. This information should complete the record and I ask that you resume review under your normal timelines."
What to include (and what not to)
Include:
- Exactly what the plan asked for
- A short cover letter listing the enclosures
- A copy of the plan's request letter (so the reviewer can match them up)
Do not include:
- Additional arguments you did not make in the original appeal (that risks the plan treating your letter as a new appeal, which restarts the clock)
- Unrelated medical records
- Documents from another episode of care
If the request seems designed to trip you up
Some plans ask for information that either (a) the plan already has in its own file, (b) was included in the original appeal, or (c) is impossible to produce. If the request looks like that:
- Provide what you can
- In the cover letter, note what the plan already has and cite the page of your original appeal
- Ask the plan to identify what is still missing before it decides
Clock impact
Under ERISA and CMS rules, the clock pauses while the plan waits for your response. Once you respond, the clock restarts. If the plan takes another 45 days, that is on top of the time already spent.
What if you cannot get the information
If the plan asks for something you cannot obtain (a record your former provider will not release, a document that does not exist), respond in writing explaining what you tried and what happened. The plan cannot deny the appeal solely for lack of information you could not obtain despite reasonable effort.
Escalate if the plan ignores your response
If you respond and then the plan tells you it never received your submission, use your certified-mail Return Receipt as proof and demand the review resume. Escalate to state DOI if the plan continues to stall.