Learn why your health insurance claim file is essential for appealing denied claims, how to request it, and what to look for when reviewing it to strengthen your case.
What is a Claim File?
A claim file contains all the documents and communications your health plan used to decide whether to approve or deny your claim. Most health plans are legally required to share this information. According to a ProPublica investigation, reviewing your claim file can help expose mistakes or misconduct by your health plan, which can make your future appeals stronger.
When Should I Request My Claim File?
You can request your claim file anytime after a denial, but we recommend doing so if your first appeal is unsuccessful. This way, you can avoid delays or extra paperwork that might interfere with a timely reconsideration. It's a smart move to have this information in hand if you need to take further steps.
Why are Claim Files Important?
Your claim file gives you insights into why your claim was denied and may reveal errors or inconsistencies that can help you in your next appeal.
Most health plans are required to provide your claim file within 30 days, so you can review it carefully.
How to Request Your Claim File
Request Your Claim File If you appealed through Claimable, don’t worry—we’ve already requested it as part of your appeal process. If not, you can use ProPublica's handy template to request it yourself.
Call to Follow Up Call your insurance company’s member services team (the number’s on your insurance card) to make sure they’re processing your request. It never hurts to check in!
File a Complaint If your insurer doesn’t provide your claim file within 30 days, it’s time to file a complaint with your state or federal regulatory agency. You’re entitled to this information.
How do I review my claim file?
Reviewing your claim file might seem daunting, but with the right checklist, you can spot important details.
Look for any missing documents or internal communications that could reveal mistakes or issues with how your claim was handled.
And remember—you can always share your claim file securely with us at Claimable if you want to participate in our ongoing research on denial issues. Just reach out at support@getclaimable.com, and we’ll send you a secure link.
Claim File Checklist
Here’s what you should look for when reviewing your file:
Question | Description |
Does it cover the right time frame? | It should include documents leading up to, during and after your denial. If documents provided do not cover the time period stated in your claim file request–it’s incomplete. |
Does it include call Recordings, transcripts and call logs? | The file should contain all phone call recordings, transcripts and/or summary logs related to communications about your claims and/or denials. If you know you or your health provider called the health plan and don’t see it in the log–it’s incomplete. |
Does it include email communications? | It should include emails relevant to the denial(s), including internal messages and communications with healthcare providers. If you know you or your health provider emailed the health plan and don’t see it in the file–it’s incomplete. |
Does it include internal messages? | The file should include internal communications among health plan staff about the evaluation or discussion of the denial(s). If the internal reasons or evidence differ from the denial notice, you may have strong grounds to challenge the decision. |
Does it include claim approval and/or denial letters? | The file should include all formal and informal notices sent to you or your healthcare provider, such as denial letters or explanation of benefits. If the denial reasons change, you may have strong grounds to challenge the decision. |
Does it include prior authorization requests and responses? | The file should include documents related to requests for authorization and their subsequent approvals or denials. If it includes medical records that were subsequently re-requested or ignored, you may have strong grounds to challenge the decision. |
Does it include internal memos or reports? | The file should include any written reports or memoranda related to the denial(s) that were sent by or received from health plan staff. Look for any inconsistencies between these communications and your denial. |
Final Thoughts
Your claim file is a powerful tool—it can give you the information you need to fight back and strengthen your appeal. We know dealing with denials can be frustrating, but Claimable is here to help. Don't hesitate to reach out if you have questions or need guidance.
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