How to Write an ABA Insurance Denial Appeal Letter

Step 1: Read the denial closely

• The exact reason: medical necessity, missing documentation, authorization, coding, out-of-network, or a benefit exclusion.
• The criteria or guideline the reviewer used (for example, the plan's ABA medical policy).
• The appeal deadline and where to send it. For many employer plans covered by ERISA, you have at least 180 days to file an internal appeal; Medicaid managed care plans usually allow 60 days. Use the date in the letter.
• Whether a peer-to-peer review is offered, and by when.
• What type of plan it is (fully insured, self-funded employer, Medicaid, marketplace), because different rules apply.

Step 2: Gather the evidence

• The current assessment and treatment plan with measurable goals and baselines.
• Progress data: graphs or tables showing change over time, and the reason for the requested hours.
• Standardized assessment results (for ABA, often VB-MAPP, ABLLS-R, Vineland or similar) and dates.
• The diagnosis documentation and a physician or psychologist referral if the plan requires it.
• Parent training participation and coordination of care notes.
• The plan's medical policy, so you can quote its criteria back.

Step 3: Answer every reason, point by point

Reviewers look for a direct response to each issue they raised. For each reason in the denial, state the reason, the evidence that answers it (with the document and page), and the criterion it meets.

1. Opening: client identifiers the plan requires, claim or reference number, date of denial, and a clear request (overturn and authorize X hours of 97153 from date to date, for example).
2. Brief clinical summary: diagnosis, current functioning, safety concerns and why services are needed now.
3. Point-by-point response to each denial reason with cited evidence.
4. Medical necessity: how the requested services meet the plan's own criteria and generally accepted standards of care.
5. Rules that apply: for example, mental health parity, ERISA full-and-fair review, or the ACA's internal appeal and external review rights.
6. Closing: the specific request, a list of enclosures, and the clinician's signature and credentials.

Common mistakes

• Sending a generic letter that doesn't address the stated reason.
• Restating the diagnosis without showing current impairment and progress.
• Missing the deadline or sending it to the wrong address.
• Leaving out the plan's own criteria.
• Not asking for external review when the internal appeal is denied and the plan allows one.

If the appeal is denied

Ask for the complete claim file and the criteria used, which ERISA plans must provide on request. Many plans allow a second-level appeal, and plans subject to the ACA generally must offer independent external review for decisions based on medical judgment. State insurance departments can also help with fully insured plans.

Frequently asked questions

Related resources

• Common Behavioral Health Claim Denials and How to Prevent Them
• Behavioral Health Documentation Audit Checklist
• Behavioral Health Treatment Plans: SMART Goal Examples