Get Appeals Form - Virginia Premier

Navigating the Appeals Form for Virginia Premier can seem daunting, but this guide will help you through each step of the online process. By following the instructions outlined below, you can ensure that your form is completed accurately and submitted efficiently.

Follow the steps to complete the Appeals Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal details. Fill in your first name, middle name, last name, city, state, zip code, contact telephone number, Virginia Premier ID number, social security number, and any alternative telephone number you may have.
3. Provide your street address or post office box to ensure proper communication.
4. Select the appropriate option indicating whether you are appealing the action of Virginia Premier Health Plan, Inc. or registering a grievance with them.
5. Enter the date mentioned in the notice you received regarding the VPHP decision.
6. Fill in the name and title of the person who informed you about the action you are appealing.
7. Indicate the specific action you are appealing by checking the relevant box. Options include denial or limited authorization of a service request, reduction, suspension, or termination of a previously authorized service, denial in whole or part of a payment for a covered service, or specify other circumstances.
8. It is important to attach a copy of the notice or letter regarding the action you are appealing or submitting as a grievance.
9. If you have a representative, fill out their details including name, address, and telephone number. This section is optional, and not having a representative does not affect your appeal.
10. Finally, include your signature along with the date to verify that you are submitting the form.
11. Once all fields are completed, you can save the changes, download the completed form, print it, or share it as needed.

Don't hesitate to complete your Appeals Form online for a swift resolution.