TEST - 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

This form is for submitting an Appeal for one member only.
The member information entered below must correspond to all appeal information listed later in the form.
If you are appealing for multiple members, please submit a separate form for each member.

*Required Fields

Please enter a valid Date.

Provider Information

Enter the information for the rendering of billing provider associated with the Appeal.

*Required Fields

Submitter Information

Enter the contact information for the individual completing this appeal form. This person may receive follow-up correspondence or status updates related to the appeal form.

*Required Fields

Appeal information

Enter the claim or reference number(s) you are appealing.
You may include up to 8 per submission, as long as they are all for the same member.
This information will be used to review your request and issue a response.

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
    Please provide only clinical notes for the date of services being appealed. : Edit

    Print this page for your records before submitting the appeal.