Get Does North Carolina Handle Marketplace Appeals Form

Filing an appeal through the Does North Carolina Handle Marketplace Appeals Form is an important step for users seeking to contest eligibility decisions. This guide provides clear, step-by-step instructions tailored to help you fill out the form effectively online.

Follow the steps to complete your appeal request successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the appellant section. Provide the first name, middle name, last name, and suffix of the person requesting the appeal. Ensure to include accurate details as this will be crucial for identification.
3. Enter the date of birth of the appellant using the format mm/dd/yyyy. This information helps verify eligibility.
4. Fill in the phone number and email address of the appellant for communication purposes. Make sure these are current and accessible.
5. Provide the street address, city, apartment or suite number, state, and ZIP code of the appellant to establish their residence.
6. List the names of other household members who are also filing an appeal. If additional space is needed, attach a separate piece of paper.
7. In the reasons for filing an appeal section, clearly explain why you believe the Marketplace made a mistake regarding eligibility. Be as detailed as possible and include specific references to the eligibility notice.
8. If applicable, indicate if the appeal for Medicaid denial will be heard by the state Medicaid agency. Select the appropriate checkbox.
9. Complete the authorized representative section if you have someone assisting you with the appeal. Fill in their contact details and organization name if relevant.
10. Read the privacy statement and sign the form. Ensure all adults listed on the application provide their signatures to authorize the release of information.
11. After completing the form, review it for accuracy and completeness before submitting it. You can save changes, download, print, or share the filled form as necessary.

Submit your appeal request online today to ensure a prompt review of your eligibility.