Sample level-of-care appeal packet, on a fictional PHP denial

What the program sent

About 5 to 10 minutes in the request form: the payer’s reason copied from the notice and a de-identified clinical picture in relative time. No files, names, ID numbers or calendar dates.

Program

Harbor Counseling Center (fictional), adult partial hospitalization program

Plan type

Commercial employer plan (no payer named in this sample)

Care setting and review

Partial hospitalization (PHP), concurrent review, first-level appeal

Days left to appeal

30 (the notice allows 30 days and arrived the day the program sent this)

Criteria cited

The plan's level-of-care guideline for mental health partial hospitalization (named in the notice; text not reproduced)

Payer's stated reason

“Continued partial hospitalization is not medically necessary. The member is not at imminent risk and symptoms can be safely treated in intensive outpatient care.”

Clinical summary

Adult with major depressive disorder, recurrent, severe. PHQ-9 21/27 at admission and 19/27 on day 8. Passive suicidal ideation without plan on day 6. Two prior IOP episodes with relapse within 3 weeks of discharge.

Anything else

Member remains in PHP while the appeal is prepared.

Evidence checklist

The second Word file, the packet guide, starts here: what to attach, what the record is missing, and what to confirm against the chart.

Attach or verify for the appeal letter

• PHQ-9 results at admission and on day 8, and any later administration for the dates at issue
• Risk assessment documenting passive suicidal ideation on day 6, and the most recent risk assessment and safety plan
• Discharge summaries for the two prior IOP episodes, showing relapse within 3 weeks of each discharge
• Current treatment plan with goals, the changes made since admission, and the discharge criteria

Evidence the denial analysis says is missing

• A functional assessment for the dates at issue: work, self-care and daily structure
• Documentation of supports at home and the barriers to stepping down
• The treatment changes since admission and when a response is expected (the summary gives none)

Level-of-care gaps to close

• Functional impairment (gap): document current functioning for the dates at issue, or have the clinician address it in the letter.
• Support and environment (gap): note who supports the member at home and what would make IOP safe.
• Active treatment and discharge plan (gap): the summary does not say what changed in treatment or when the member would be ready to step down; the clinician fills the bracketed lines in the letter from the chart.
• Risk (partly supported): add the most recent risk assessment so the reviewer sees risk on the dates at issue, not only on day 6.

Facts to confirm before you submit

• The notice date, the first non-covered date and the number of days requested
• The exact name and edition of the guideline the notice cites
• That the member is still in PHP when the appeal is filed

Criteria crosswalk

One row per reason the denial turns on, with the evidence quoted word for word from the summary and an honest status. The letter claims nothing stronger than these statuses. Licensed criteria text is never reproduced. Build your own with the free crosswalk builder.

Peer-to-peer brief

For the treating clinician to read in the two minutes before the call. It prepares the points; the clinician makes them in their own words.

Deadline and escalation plan

• The filing deadline. You told us 30 days were left when you sent the case. Confirm the exact date on the notice and calendar the earliest deadline; this plan never supplies a date you did not give us.
• While the member is in care. Ask for the peer-to-peer now, and ask the treating clinician whether waiting could seriously jeopardize the member's health. If so, request an expedited appeal; for urgent cases, decisions are due within 72 hours.
• What happens next. First-level internal appeal, then a second level if the plan has one (the decision letter says), then independent external review after the plan's final denial. The member or an authorized representative usually files external review, so get the member's written authorization early.

What a person checks before release

Automated checks run first. Then a person on the ClaimParrot team works through this list for every packet, and nothing is delivered until each item is ticked. This check is not clinical review: the treating clinician verifies every clinical statement before signing.

• Every clinical fact in the letter is in the program's summary, in its own words: nothing added, strengthened (such as “severe” or “throughout”) or rounded.
• No invented names, ID numbers, dates, scores, reviewer names or authorization numbers.
• No statute, regulation, case or criteria text unless the program supplied it; criteria are named only as the program named them.
• Placeholders such as [Member name] are intact, and none was filled with a guess.
• The payer's stated reason is quoted and answered point by point.
• The requests are specific and fit the case, and the tone is firm without guarantees or exaggeration.
• The letter and the deadline plan give no date the program did not supply, and the crosswalk statuses are honest.

ClaimParrot drafts appeal materials for review by your team. It does not determine medical necessity, give legal or medical advice, contact the payer or promise an outcome.