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

What the program sent

About ten 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, as printed on the notice

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.

Appeal letter draft

The first Word file. It quotes the denial reason, answers it point by point using only facts from the summary, and makes one specific request. The treating clinician edits and signs it.

[Date]

[Plan name], Appeals Department
[Appeals address or fax number from the notice]

Re: First-level appeal of a level-of-care denial: continued partial hospitalization
Member: [Member name]    Member ID: [Member ID]
Authorization or claim number: [Reference number]
Dates at issue: [First non-covered date] onward

Dear [Reviewer name],

We appeal the determination dated [Notice date] that denied continued partial hospitalization for the member named above. The notice states: "Continued partial hospitalization is not medically necessary. The member is not at imminent risk and symptoms can be safely treated in intensive outpatient care." It cites [the plan's level-of-care guideline for partial hospitalization, as named in the notice]. The record does not support a step-down to intensive outpatient care at this time.

1. Symptoms remain severe. The member's PHQ-9 was 21 of 27 at admission and 19 of 27 on day 8 of partial hospitalization, a change of two points while in daily programming.

2. Risk is current, not historical. Passive suicidal ideation without a plan was documented on day 6, during the current episode of care.

3. Intensive outpatient care has been tried and did not hold. The member has had two prior IOP episodes, each followed by relapse within 3 weeks of discharge. Stepping down to the level that did not hold twice is not a safe alternative while symptoms remain at this severity.

We ask that you overturn the denial and authorize continued partial hospitalization for [number of days requested] from [first non-covered date], with a step-down plan to [next level of care] when [step-down criteria]. If the denial is not overturned on the written record, we ask for a peer-to-peer review with a board-certified psychiatrist, and for a written decision that names the specific criterion found unmet and the next level of appeal.

[Clinician name, credentials], the treating clinician, has reviewed this letter and attests that, in their clinical judgment, continued partial hospitalization is medically necessary for the dates at issue.

[Signature]
[Clinician name, credentials, role]
[Program name, phone, fax]

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
• Discharge summaries for the two prior IOP episodes, showing relapse within 3 weeks of each discharge
• Current treatment plan with goals and the step-down 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

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.
• 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. 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.

Deadline and escalation plan

• The filing deadline. You told us the notice gives 30 days to appeal. 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.

• Every clinical fact in the letter is in the program's summary, in its own words: nothing added, strengthened 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.