Asking a health plan for the claim file and the criteria it used

Federal rules give people in job-based, Marketplace and other individual plans a right to free copies of the papers behind a denial. This page sets out what the rules count. It does not judge any denial.

Which plans these rules reach

• Job-based plans covered by ERISA follow the Labor Department's claims rule, 29 CFR 2560.503-1.
• Insured group and individual plans, including Marketplace plans, follow the same rule plus extra steps (45 CFR 147.136(b)). Older "grandfathered" plans are generally outside the extra steps (45 CFR 147.136(a)(1)(ii)).
• Medicare Advantage and Texas-regulated plans have their own notice duties (last section).

What the plan must hand over

On request and free of charge, the plan must give "reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits" (29 CFR 2560.503-1(h)(2)(iii)). Under 29 CFR 2560.503-1(m)(8), a paper is "relevant" if it:

1. was relied upon in making the decision;
2. was submitted, considered or generated in making the decision, even if not relied upon;
3. shows that the plan followed its required processes and safeguards; or
4. is a statement of policy or guidance about the denied treatment for the diagnosis, even if nobody relied on it.

The criterion and the clinical explanation

• If the plan relied on an internal rule, guideline, protocol or similar criterion, the denial must either include it or say that one was used and that a copy is free on request (29 CFR 2560.503-1(g)(1)(v)(A)).
• For a medical-necessity denial, the notice must give "an explanation of the scientific or clinical judgment for the determination", applying the plan's terms to the person's medical circumstances, or say the explanation is free on request (29 CFR 2560.503-1(g)(1)(v)(B)).

Extra rights in Marketplace and other ACA plans

• The plan "must allow a claimant to review the claim file and to present evidence and testimony" (45 CFR 147.136(b)(2)(ii)(C); (b)(3)(ii)(C) for individual plans).
• Before a final denial, the plan must send, free and in time to respond, any new or additional evidence it considered or generated, and any new rationale (the same paragraphs, (C)(1)-(2)).
• The diagnosis and treatment codes, with their meanings, must be given on request. A request for the codes is not, by itself, an appeal (45 CFR 147.136(b)(2)(ii)(E)(1)-(2)).

What a written request can list

The rules set no form. A request letter commonly names:

• the plan, the member ID, the claim or reference number, and the date on the denial letter;
• the rule sections above and the four kinds of "relevant" papers;
• the criterion relied on, and the clinical explanation;
• where to send the copies.

The rule text prints no number of days for sending the copies, and nothing in it pauses the appeal deadline while a request is open. For job-based plans that deadline is at least 180 days from receipt of the denial (29 CFR 2560.503-1(h)(3)(i)). HealthCare.gov suggests keeping copies of everything sent and received.

Medicare Advantage and Texas-regulated plans

• Medicare Advantage plans must follow Medicare's coverage rules. Any extra internal criteria they use must be "publicly accessible", with the evidence behind them (42 CFR 422.101(b)(6)). This page does not cover a case-file request to these plans.
• For plans with "TDI" or "DOI" on the card, the Texas rule says the denial notice must give "a description or the source of the screening criteria" used (28 TAC 19.1709(c)(3)).
• Records from a doctor's office follow a separate rule, covered on the page about "not enough information" denials.

Free public help

• The plan's member line, printed on the card.
• Texas Department of Insurance, for plans with "TDI" or "DOI" on the card: 800-252-3439.
• Office of Public Insurance Counsel (OPIC), the state office that speaks for insurance consumers: 1-877-611-6742.
• Texas Medicare help line: 800-252-9240.

What Denial Reply prepares

Denial Reply prepares appeal paperwork for Texas adults from the denial letter and records, including a request to the plan, for the patient to sign, for the criterion used and the claim file. The free decoder needs no upload.

Related guides: what a denial notice must include · the 72-hour urgent appeal · which kind of plan you have

Sources

• 29 CFR 2560.503-1: https://www.law.cornell.edu/cfr/text/29/2560.503-1 (read 2026-11-03)
• 45 CFR 147.136: https://www.law.cornell.edu/cfr/text/45/147.136 (read 2026-11-03)
• HealthCare.gov, "Internal appeals": https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/ (read 2026-11-03)
• 42 CFR 422.101 (2025 edition): https://www.govinfo.gov/content/pkg/CFR-2025-title42-vol3/xml/CFR-2025-title42-vol3-part422.xml (read 2026-11-03)
• 28 TAC 19.1709: https://www.law.cornell.edu/regulations/texas/28-Tex-Admin-Code-SS-19-1709 (read 2026-11-03)