Provider Appeal Form

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

Are you submitting this appeal at the request of a member? Yes

Member Information

*Required Fields

Member First Name

Member Last Name

Member Date of Birth

Please enter a valid Date.

Member Phone Number

Group Number

Member ID Number

Provider Information

*Required Fields

Facility Name

Provider First Name

Provider Last Name

Provider NPI

Submitter Information

*Required Fields

Submitter First Name

Submitter Last Name

Address Line 1

Address Line 2

City

ZIP Code

Phone Number

Fax Number

Appeal information

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Member information

Member First Name : Edit

MI : Edit

Member Last Name : Edit

Group Number : Edit

Member ID Number :

Member Date of Birth : Edit

Member Phone Number : Edit

Provider information

Facility Name : Edit

Provider First Name : Edit

MI : Edit

Provider Last Name : Edit

Provider NPI : Edit

Submitter information

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 Number : Edit

Fax : Edit

Timeline: Standard

Signature/authorization

First Name

Last Name

I accept

By typing my name and checking this box, I understand that I am creating an electronic signature that carries the same legal obligations as a written signature and am agreeing to all terms and conditions.

If I do not check this box my appeal will not be processed.

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Print this page for your records before submitting the appeal.

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Provider Appeal Form

Member Information

Provider Information

Submitter Information

Appeal information

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