Appeal Letter Builder

Last reviewed October 17, 2026

Written by Aptiva Health Editorial Team · Reviewed by Taylor Sorrels, Esq. and Crystal Brake, RCM Director · Editorial & review standards · How we research

A clear letter helps your plan see exactly what you are asking for and why. The Appeal Letter Builder gives you a starting draft that you can finish and send.

How to use the Appeal Letter Builder

1. Pick the letter type. Choose an internal appeal to your plan, or an external review request for Kentucky or Indiana.
2. Pick the denial and procedure. Choose the denial type and the procedure, such as MRI, physical therapy or an epidural steroid injection.
3. Fill in the fields. Add details from your denial letter, like the claim number and the exact reason. Skip any field you don’t know yet.
4. Check the draft. The letter builds as you type. Any blank field stays in [brackets] so you can fill it in by hand.
5. Save your letter. Copy it, print it, or download it as a Word (.docx) or PDF file.

What your results mean

You get a draft letter, not a finished one. The letters are the same samples used in the Hub’s guides, and they are still waiting for expert review. Read every line before you send it. Change anything that doesn’t fit your case.

Look for brackets. Anything still in [brackets] needs your input. Fill it in by hand or go back and add it in the tool.

Attach your evidence. A letter works best with proof behind it. Plans must let you send written comments, documents and records with your appeal. The appeal must take into account everything you send, even if it was not part of the first decision (29 CFR 2560.503-1(h)(2)). Attach your clinician’s letter and the medical records that answer the denial reason. The guides explain what records often help, for example for denials as “not medically necessary” or for missing prior authorization.

Send it the right way. Send your letter the way your denial letter says: by fax, mail or the plan’s online portal. Get proof that you sent it, like a fax confirmation, a mail receipt or a portal screenshot. Keep copies of everything you send.

External review requests

Kentucky. You ask for external review through your insurer, not the state. Your insurer completes form HIPMC-IRE-6 (KY DOI Form HIPMC-IRE-6). Your part is to give written consent so the reviewer can get your medical records (KRS 304.17A-623). The Kentucky letter mentions that you have signed this release. The reviewer must consider information from you and your provider, not just your insurer’s file (KRS 304.17A-625). See the Kentucky guide for the full steps.

Indiana. You file a written request with your insurer (IC 27-8-29-13). Indiana has no state form, so check your EOB or policy for your insurer’s instructions (IDOI: Grievance Procedures). You can send more information throughout the review (IC 27-8-29-14). See the Indiana guide.

Where the deadlines and rules come from

The letter builder does not set your deadline. To find it, use the Appeal Deadline Calculator and check your denial letter. The rules on this page come from federal claims rules (29 CFR 2560.503-1), Kentucky statutes and Department of Insurance forms, and the Indiana Code. Each source is linked above and listed on this page.

What this tool can’t do

• It can’t write your clinician’s letter or collect your records.
• It doesn’t know your plan’s own rules or the exact reason in your letter unless you type it.
• It doesn’t send the letter for you.
• It can’t tell you whether your appeal will succeed.
• The sample wording may not fit every situation. Change it to match your letter.

Your privacy

What you type stays in your browser. The letter is built on your device, and the Word and PDF files are made there too. Nothing is sent to Aptiva or saved. If you choose the optional “email me” feature, only your email address, state, plan type and the tool name are sent. Your letter is never sent. If you close the page, your draft may be lost, so save a copy first.