Appeal My Claim

Appeal rights, steps and free help for a plan type and state. For requests like "what are my appeal rights in California?", "my insurer denied my claim, what can I do?" or "how do Medicare appeals work?". Returns who decides, the steps (internal appeal, external review, Medicare levels or Medicaid fair hearing), deadlines, and where to get free help, including the state insurance department. If the plan type is not known, leave it out to get the rules for most private plans.

{
  "type": "object",
  "properties": {
    "state": {
      "type": "string",
      "description": "US state name or two-letter code, like California or CA. Puerto Rico works too."
    },
    "plan_type": {
      "type": "string",
      "description": "Plan type: marketplace, employer, employer_insured, employer_self_funded, medicare, medicare_advantage, part_d or medicaid. Everyday words work too, like \"job\", \"Obamacare\" or \"Medi-Cal\". Default: most private plans."
    }
  },
  "required": [],
  "additionalProperties": false
}

How long someone has to appeal, and how fast the plan must decide. For requests like "how long do I have to appeal?", "when is my appeal due?" or "how fast does my insurer have to answer?". With the date on the denial notice, gives an approximate file-by date. The date on the user's own notice is the one that counts.

{
  "type": "object",
  "properties": {
    "plan_type": {
      "type": "string",
      "description": "Same values as plan_type in get_appeal_rights. Default: most private plans."
    },
    "denial_date": {
      "type": "string",
      "description": "Date on the denial notice, like 2026-09-01, 09/01/2026 or September 1, 2026."
    },
    "urgent": {
      "type": "string",
      "enum": [
        "yes",
        "no"
      ],
      "description": "Set to yes if waiting could seriously harm the person's health."
    }
  },
  "required": [],
  "additionalProperties": false
}

Explain the denial codes on an Explanation of Benefits. For requests like "my EOB says CO-50, what does that mean?", "what is denial code PR 204?" or "what does N130 mean?". Returns each code in plain words, who usually fixes it (the provider's billing office, an appeal, or the user), whether the provider can bill the user for it (from the group code CO, PR, OA or PI), and a letter link when an appeal fits.

{
  "type": "object",
  "properties": {
    "code": {
      "type": "string",
      "description": "One to four codes from the notice, like CO-50, PR 204, 197 or N130."
    },
    "plan_type": {
      "type": "string",
      "description": "Same values as plan_type in get_appeal_rights. Carried into the letter link."
    }
  },
  "required": [
    "code"
  ],
  "additionalProperties": false
}

Draft an appeal letter for the user to review and send. For requests like "my insurer denied my MRI as not medically necessary, help me appeal" or "write an appeal letter for an out-of-network denial". Returns a letter as plain text with [brackets] for anything not given, a checklist of what to attach (denial notice, doctor's letter of medical necessity, records), and tips. It never sends or files anything.

{
  "type": "object",
  "properties": {
    "reason": {
      "type": "string",
      "enum": [
        "medical_necessity",
        "emergency",
        "experimental",
        "out_of_network",
        "prior_auth",
        "coding",
        "generic"
      ],
      "description": "Why the claim was denied: medical_necessity, emergency (said it wasn't an emergency), experimental, out_of_network, prior_auth, coding or generic. Required unless denial_code is given."
    },
    "denial_code": {
      "type": "string",
      "description": "The reason code on the notice, like CO-50 or PR-197. Picks the reason when reason is left out, and is quoted in the letter."
    },
    "plan_type": {
      "type": "string",
      "description": "Same values as plan_type in get_appeal_rights. Changes the wording for Medicare."
    },
    "name": {
      "type": "string",
      "description": "Member's name."
    },
    "plan": {
      "type": "string",
      "description": "Insurer or plan name."
    },
    "member_id": {
      "type": "string",
      "description": "Member ID or Medicare number."
    },
    "claim": {
      "type": "string",
      "description": "Claim or reference number."
    },
    "service": {
      "type": "string",
      "description": "The care that was denied, like \"MRI of the right knee\"."
    },
    "date": {
      "type": "string",
      "description": "Date of service."
    },
    "denial_date": {
      "type": "string",
      "description": "Date on the denial notice."
    },
    "doctor": {
      "type": "string",
      "description": "Treating doctor's name."
    },
    "provider": {
      "type": "string",
      "description": "Hospital, clinic or provider name."
    },
    "details": {
      "type": "string",
      "description": "A sentence or two in the user's words on why the care should be covered."
    },
    "urgent": {
      "type": "string",
      "enum": [
        "yes",
        "no"
      ],
      "description": "Set to yes to ask for an expedited review."
    }
  },
  "required": [],
  "additionalProperties": false
}