Provider Appeal Form (Online Version)

The appeal form should not be used to submit a claim correction or as a venue for submitting medical records or EOBs.

Member Information

*Required Fields

Provider Information

*Required Fields

Submitter Information

*Required Fields

Appeal information

Appeals Documentation

Max size for upload is 10MB. Acceptable file formats include: .pdf and image files.

    Almost done! Review your information

    Member First Name : Edit
    MI : Edit
    Member Last Name : Edit
    Member ID Number : Edit
    Member Date of Birth : Edit
    Phone : Edit
    Facility : Edit
    First Name : Edit
    MI : Edit
    Last Name : Edit
    Provider NPI : Edit
    Submitter First Name : Edit
    MI : Edit
    Submitter Last Name : Edit
    Address Line 1 : Edit
    Address Line 2 : Edit
    City : Edit
    State : Edit
    ZIP Code : Edit
    Phone : Edit
    Fax : Edit

    Print this page for your records before submitting the appeal.