Follow the steps to complete your appeal submission form.

1. Click ‘Get Form’ button to obtain the form and open it in the appropriate editor.
2. Fill in your personal information in the designated fields, including your patient name, member ID number, address, phone number, and group name/number.
3. Provide details about the benefit denial you wish to appeal. Include the claim number(s) and case (authorization) number in the respective fields.
4. Select the appeal level by checking the applicable option: Level 1, Level 2, or External Review (if applicable).
5. On a separate page, clearly outline the reasons for your appeal and any supporting documents, such as medical records, that you wish to attach.
6. Enter the date of the notice of benefit denial in the specified field.
7. Sign the form either as the patient or their guardian, and date your signature in the required areas.
8. If desired, complete Section 2 to appoint an authorized representative by filling in their name, relationship to you, and contact information.
9. If the appeal is urgent, complete Section 3 by having your treating provider certify the urgency, including their signature and contact details.
10. After reviewing all the information for accuracy, save changes to your form, and if needed, download, print, or share it as appropriate.

Complete your Appeal Submission Form online today to ensure your claims are reviewed promptly.