Insurance letters are hard to write when you are tired and worried about your child's care. This builder gives you a starting draft for the most common reasons ABA is denied. You can edit the draft before you use it, and it explains what documents to attach.
Private by design. The letter is built in your browser. Nothing you type is sent to ABA Navigator or anyone else, and this page has no form that submits to a server. Close the page and the details are gone.
General information, not legal advice. This tool helps you draft a letter. It does not know the rules of your specific plan or state, and it cannot promise any outcome. Read your denial letter and plan documents, and follow the deadlines and instructions they give.
Step 1: Choose the reason for the denial
Step 2: Add your details
Anything you leave blank shows up in the letter as a bracketed placeholder, like [CLAIM NUMBER], so you can fill it in by hand.
Use this if waiting could seriously harm your child's health or development. Plans usually want a doctor's support for this, so ask your child's doctor to back the request.
A few specific sentences carry weight, for example skills your child has gained or safety concerns. This text goes into the letter exactly as you type it.
What to attach for this denial reason
- A copy of the denial letter
- The diagnostic evaluation report that confirms the autism diagnosis
- The BCBA's assessment and written treatment plan, including goals and the hours recommended
- Recent progress data or graphs, if therapy has already started
- A letter of support from your child's doctor, psychologist or other treating professional
- Reports from school, speech therapy or other providers that show the needs ABA is meant to address
- A copy of the denial or authorization letter showing the hours approved
- The treatment plan showing the hours requested and the goals each hour supports
- The most recent assessment results and a short letter from the BCBA explaining why the requested hours are needed
- Progress data from the current authorization period
- Notes about any changes since the last authorization, such as new goals, new settings or new safety concerns
- A copy of the denial letter
- A log of the in-network ABA providers you contacted: name, date, who you spoke with, and the answer (no openings, waitlist length, does not serve your child's age or needs)
- The provider's name, credentials and a short statement of why they are the right fit for your child
- The BCBA or doctor's recommendation, if the choice of provider is based on your child's needs
- Your plan's directory pages or screenshots showing the in-network options you tried
- A copy of the denial or the insurer's request for more information
- Every document the insurer says it is missing, labeled to match its request
- The diagnostic report, referral or prescription, and the treatment plan, if they were requested
- Proof that you or your provider already sent the documents, such as fax confirmations or portal screenshots
- A short note listing what you attached so the reviewer can check it off
- A copy of the denial letter that names the limit
- The page of your plan documents (summary of benefits or full plan document) that states the limit, or a note that you asked for it and did not receive it
- The diagnostic report and the BCBA's treatment plan
- A count of the visits or hours used so far, from your explanation of benefits statements or your provider
- A letter from your child's doctor or BCBA explaining why continued treatment is needed
Always keep a copy of everything you send, and use a delivery method that gives you proof of receipt.
Step 3: Review, copy, download or print
Changing the boxes above rebuilds the letter until you edit the letter itself. After that, use the rebuild button to start over.
The general steps of an appeal
- Read the denial letter closely. Find the reason for the denial, the deadline to appeal, and where to send the appeal. Ask your plan for the clinical criteria or plan language it used. You can request your claim file free of charge.
- Ask the provider to help. Call your provider's billing or authorization team. Many denials are fixed by a peer-to-peer call between the BCBA or physician and the insurer's reviewer, or by sending a missing document.
- File an internal appeal in writing. Send your appeal letter and supporting documents before the deadline, using a method that gives you proof of delivery. Keep a copy of everything.
- Track the decision deadline. Plans must decide within set timeframes, which your plan documents or denial letter list. Ask for an expedited review if delay would seriously harm your child's health or development, and ask your child's doctor to support that request.
- Request an external review if the denial is upheld. If your plan upholds the denial, ask for an external review by an independent reviewer. The request is usually due within four months of the final internal denial.
- Get outside help if you are stuck. Your state insurance department, your employer's benefits office (for employer plans), or a consumer assistance program can explain your options.
The federal rules for internal appeals and external review that apply to most health plans that are not grandfathered are summarized by HealthCare.gov, Appealing a health plan decision, and set out in 45 CFR 147.136. Some plans, including some grandfathered plans and Medicaid, follow different rules, so your denial letter is the first place to look for your deadlines and options.
Frequently asked questions
Is anything I type saved or sent to ABA Navigator?
No. The letter is assembled by your browser. There is no form submission, and the details you enter are not sent to us or stored. When you close or reload the page, they are gone.
Is this legal advice?
No. This is general information and a drafting aid. It is not legal advice and does not create an attorney-client relationship. Plans and states differ, so read your denial letter and plan documents, and consider asking your state insurance department, your employer's benefits office, or a lawyer if the stakes are high.
How long do I have to appeal?
Your denial letter should state the deadline for your plan. For plans that are not grandfathered, federal rules require the plan to allow at least 180 days from the denial notice to file an internal appeal. Do not wait. File as early as you can and keep proof of when you sent it.
What happens if the internal appeal is denied?
For plans covered by the federal rules, you can generally ask for an external review, where an independent reviewer who does not work for your insurer looks at the decision. Your final denial letter should explain how and by when to ask.
Does this work for Medicaid?
Medicaid has its own appeal and state fair hearing process, with its own deadlines, and the federal external review process described here does not apply the same way. You can adapt the letter, but follow the instructions in your denial notice.
Ready to talk to a provider?
If you are still choosing or changing providers, you can search by location and insurance. Your provider's authorization team can often help with an appeal.
This page is general information, not legal advice.