How a case moves through Tarian

1. ✓ 1. Your denial letter, read and explained

   Insurer: Northgate Insurance Co

   Denial reason: Missing prior authorization: The claim was denied because prior authorization wasn't obtained before treatment.

   Service: Lumbar spine MRI without contrast (CPT 72148), performed January 22, 2026

   Plan type you confirmed: Employer plan, self-funded (federal ERISA rules)

   Amount at stake: $2400.00

   Computed deadlines

   From the notice date on the letter (2026-02-03) plus the published minimum. The letter itself controls if it states a different date.

   • File your internal appealcomputed 2026-08-02
   • Insurer must decide (post-service)computed 2026-04-11
   • Request external reviewcomputed 2026-06-10

   What appeals for this reason commonly include

   • The denial letter itself.
   • The Explanation of Benefits (EOB) for the claim, if you received one.
   • Your plan's Summary Plan Description (SPD) or Evidence of Coverage (EOC).
   • Any record of authorization requests, reference numbers, or calls to the plan before treatment.
   • A statement from the provider's office about whether authorization was requested, and any retroactive authorization or peer-to-peer review request they have filed.

2. ✓ 2. A short interview, then a drafted letter you edit and approve

   AI-generated draft from your answers — review before use.

   Northgate Insurance Co
   Appeals Department
   
   Re: Appeal of denial — Member ID NGI-445566, Claim CLM-2026-009981
   Service: lumbar spine MRI without contrast (CPT 72148), January 22, 2026
   
   To the Appeals Department:
   
   I am appealing the denial dated February 3, 2026. The denial states that prior authorization was required for this imaging and was not obtained before the service.
   
   The MRI was ordered by my treating physician, Dr. A. Example, after six weeks of conservative treatment for low back pain with radiating leg symptoms, documented in the enclosed notes (Exhibit B). The order was placed and the scan scheduled by the physician's office; I was not told an authorization was needed and had no way to obtain one myself. The enclosed explanation of benefits (Exhibit C) shows the claim as denied in full, leaving a balance of $2,400.
   
   The denial does not state whether the plan considers the MRI medically necessary, only that the authorization step was missed. I ask that the plan review the claim on its medical merits, identify the plan provision that makes authorization a condition of coverage, and state whether that provision allows a retroactive authorization where the ordering provider failed to request one.
   
   I request that the denial be reversed and the claim paid according to the plan's terms. Please send your decision to me at the address on file within the time the plan's procedures allow.
   
   Enclosures: Exhibit A, denial letter; Exhibit B, physician's order and clinical notes; Exhibit C, explanation of benefits.
   
   Sincerely,
   Priya Example

   Exhibits selected: Denial letter, Referring physician's order and notes, Explanation of benefits.

   Open the sample packet (PDF)Approve for filing

3. ✓ 3. Filed, with proof

   You can send the packet yourself (certified mail or fax) and confirm the date here, or sign a short authorization and have it faxed for you, with the carrier's delivery receipt kept on the case.

   Filed: 2026-02-10

   Fax receipt: 5 pages to (555) 010-0244, delivered 2026-02-10, ref fax_01HZ...demo2

   Insurer decision due: around 2026-04-11, counted from the filing date, under the published timeline. We remind you a week before and the day after.

4. ✓ 4. The insurer's response arrives

   Fax received 2026-03-02 from (555) 010-0244, matched to this case by the reference code on the cover sheet, and confirmed by the patient before anything was shown.

   Looks like a request for more information

   The plan acknowledges the appeal and asks for the ordering physician's clinical notes from the visit at which the MRI was ordered, and for any record of an authorization request, before it decides.

   Mentions a deadline of 2026-04-01 — confirm this on the original document.

   View original documentYes, this is about my case

5. 5. The next document is already draftedyou are here

   The plan asked for more records before deciding, so a reply is drafted and waiting. Edit it, approve it, and send it with the records the plan asked for.

   AI-generated draft from your answers — review before use.

   Northgate Insurance Co
   Appeals Department
   
   Re: Status of appeal — Member ID NGI-445566, Claim CLM-2026-009981
   
   I filed an internal appeal of the denial dated February 3, 2026, on February 10, 2026. Under the plan's published decision timeline a decision was due by April 11, 2026, and I have not received one.
   
   Please confirm the date my appeal was received, its current status, and the date by which I can expect a written decision. If any information is missing from my appeal, please tell me what it is.
   
   Sincerely,
   Priya Example

   ApproveSend by fax

6. 6. What comes after, laid out as options

   • External review decision (binding on the plan; standard review decided within 45 days).
   • For a self-funded employer plan, the state insurance department has no authority; the federal Employee Benefits Security Administration takes inquiries.
   • Free human help from a state Consumer Assistance Program, where one operates.
   • For a self-funded employer plan, a lawsuit in federal court would be a possible later step; that requires a lawyer.

   We show every route with the rule it rests on. We never pick one for you.

Tarian is a self-help software tool, not a law firm, insurance company, or medical provider. Nothing here is legal, medical, or insurance advice, and it is not a substitute for the advice of an attorney. You review and approve everything before it's used.