Appeals and external reviews turn on whether the evidence is complete, dated, and consistent — reviewers routinely discount exhibits that are undated, out of order, or look altered. This free page gives you the evidence checklist reviewers actually expect (itemized bill, EOB, denial letter with CARC codes, medical records excerpts, prior-authorization records, a dated call log, and a timeline) plus a paste-ready cover sheet that lists each exhibit by date and description.
At minimum: the itemized bill, the insurer's Explanation of Benefits (EOB), the denial letter with its CARC/RARC reason codes, the relevant excerpts of your medical records, any prior-authorization paperwork, and a dated log of every call you made (date, time, representative name, and reference number). A timeline table tying dates of service to dates of denial, appeal, and follow-up ties the exhibits together for the reviewer.
Keep every document dated and in its original form — screenshots and photos of physical mail work, but note the date you received it. Log every phone call the same day it happens, while the details are fresh. Build a simple timeline as you go rather than reconstructing it later.
External review (the final independent review after internal appeals are exhausted) is decided on the written record alone — there's no hearing to fill gaps verbally. The evidence cover sheet below gives the independent reviewer a dated exhibit list up front, which is exactly the format most external-review programs expect submissions in.
Medigami's $59 Certified Evidence Pack seals your evidence on a tamper-evident, hash-chained receipt with a public verification page — so a payer or reviewer can confirm nothing was altered after the fact. Or get the full appeal drafted for you with Bill Rescue ($149, done in 48 hours).
Educational free template only. Not legal or medical advice. Consult your plan documents, denial letter, and where appropriate a licensed attorney or state-certified insurance counselor.
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Educational tool — not legal, medical, or billing-counsel advice. Treatment and appeal decisions remain with you and your physician / counsel.