Get Appeal Submission Form

Filing an appeal can be a critical step in addressing a denial of benefits. This guide provides clear instructions on how to fill out the APPEAL SUBMISSION FORM online, ensuring that you understand each section and can submit your appeal successfully.

Follow the steps to complete your appeal submission form.

1. Press the ‘Get Form’ button to access the APPEAL SUBMISSION FORM and open it in your preferred online editor.
2. In Section 1, fill in the required fields including your Patient Name, Member ID Number, Address, Phone Number, and Group Name/Group Number. Provide the Claim Number(s) and Case (authorization) Number, then select the applicable appeal level by checking the appropriate option.
3. On a separate page, clearly describe the reasons why you believe the benefit denial should be overturned. Be sure to attach any relevant documentation, such as medical records or chart notes.
4. Complete the Date of Notice of Benefit Denial section and ensure that either you or your guardian provides a signature in the designated area along with the date.
5. If you choose to appoint an authorized representative, complete Section 2 by providing their name, relationship to you, address, and phone number. Make sure to sign and date this section as well.
6. For an urgent pre-service appeal, complete Section 3 if applicable. Have your physician certify that the procedure or service meets the Department of Labor's criteria for urgent processing by signing, printing their name, and providing their contact details.
7. Finally, review all filled sections for accuracy, make necessary changes, and when ready, save your changes, and download, print, or share the form as needed.

Complete your appeal submission online today to ensure your voice is heard.