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.

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

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

Add Another Reference

*Required Fields

Claims Number

Reference Number

Date of Service

Please enter a valid Date, mm/dd/yyyy

Total Charge Amount

In fine detail, explain your disagreement and why you are requesting the determination to be reviewed.

Please attach any information you think will help overtrun the original decision such as physician's notes, operation reports, x-rays, lab results.

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

Attach

Add Another Claim

Appeals Documentation

Please attach any information you think will help overturn the original decision such as physician's notes, operation report, x-rays, lab results.

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

Attach File

Almost done! Review your information

Member information

Member First Name : Edit

MI : Edit

Member Last Name : Edit

Member ID Number : Edit

Member Date of Birth : Edit

Phone : Edit

Provider information

Facility : Edit

First Name : Edit

MI : Edit

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 : Edit

Fax : Edit

Timeline: Standard

Print this page

Print this page for your records before submitting the appeal.

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TEST - Provider Appeal Form (Online Version)

Member Information

Provider Information

Submitter Information

Appeal information

Appeals Documentation

Almost done! Review your information