Coverage Rights — Free appeal preparation worksheet Prepared October 7, 2026 Use this blank worksheet while you confirm an unclear denial reason or appeal route. Leave unknown details marked UNKNOWN; do not guess. It does not determine coverage, establish medical necessity, calculate a deadline or choose a treatment. 1. WHAT THE NOTICE ACTUALLY SAYS Service or item named in the notice: ____________________ Exact denial wording: ____________________ Denial reason/category, if confirmed (otherwise UNKNOWN): ____________________ Plan rule or criterion cited (otherwise UNKNOWN): ____________________ Question to ask: Which reason and exact rule apply, and what information was missing? 2. COVERAGE FACTS TO CONFIRM Plan name and coverage type: ____________________ For employer coverage, employer type and plan funding (or UNKNOWN): ____________________ Source to check, such as the plan document, card or notice: ____________________ Current appeal stage (or UNKNOWN): ____________________ 3. AVAILABLE RECORDS — ALREADY IN MY POSSESSION Record: ____________________ What it may help explain: ____________________ Having a record does not establish that it satisfies the plan's rule or that the plan has received it. Do not list a document as enclosed unless you include it. 4. MISSING RECORDS OR EXPLANATIONS — STILL TO REQUEST Record or explanation: ____________________ Who I can ask, such as the clinician or plan: ____________________ Question or request to make: ____________________ Keep the request on this list until you know what was actually provided. 5. UNVERIFIED REQUIREMENTS AND FILING DETAILS Exact plan policy/criterion still to confirm: ____________________ Filing recipient and submission channel from the applicable instructions (or UNKNOWN): ____________________ Deadline printed on the notice, if present (otherwise UNKNOWN): ____________________ What I still need to verify about that deadline and route: ____________________ Do not treat a copied date, a follow-up target or an example as a verified deadline. 6. MY NEXT ACTION One next step, such as confirming a plan fact or requesting a relevant record: ____________________ Who I will contact: ____________________ When I would like to follow up (optional): ____________________ This is a personal follow-up target, not an appeal filing deadline or an automatic reminder. What reply or document I am waiting for: ____________________ KEEP YOUR WORK Save or print your completed copy privately. This is a blank download, not an account backup or an import file for the organizer. Nothing you write in this downloaded file is automatically sent to Coverage Rights. No account or payment is required for this worksheet. It does not submit an appeal, request records, verify receipt or send reminders. You remain responsible for checking the applicable instructions and making any submission. Return to the free route check when you have confirmed the missing facts: https://www.coverage-rights.com/tools/explain-my-denial Preview the free organizer separately; this worksheet is not imported: https://www.coverage-rights.com/workspace Coverage Rights is a self-help tool, not legal or medical advice.