Get Member Appeal Request Form

Filling out the Member Appeal Request Form can be straightforward if you follow the correct steps. This guide will provide you with clear and concise instructions on how to efficiently complete the form online.

Follow the steps to successfully submit your appeal request.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date and time at which you are completing the form. This information helps track your appeal process.
3. Provide your full name in the 'Member Name' field along with your Member ID number. This information is crucial for identifying your account.
4. If you are completing the form on someone else's behalf, fill out the 'Requested By' section with your name, including your phone number and relationship to the member.
5. Indicate whether you prefer communication via e-mail by selecting 'Yes' or 'No.' If you select 'Yes,' enter your email address.
6. Fill in the address of the person requesting the appeal. This ensures that all correspondence reaches the correct individual.
7. Specify the nature of your appeal by describing the denied services or coverage. You may include detailed information about the specific service or treatment.
8. Indicate who referred you for the service in the 'Referred by' section, whether it was you or your physician.
9. If applicable, include the names of other providers from whom Group Health should retrieve records.
10. Select one or more options from the provided reasons for your appeal. Choose all relevant options that apply to your situation.
11. Add any additional information that supports your case in the specified section to provide context to your appeal.
12. Before finalizing your form, ensure that you have attached any necessary documents that support your appeal, including denial documents.
13. Review all the information entered for accuracy and completeness before proceeding to submit your appeal.
14. Once everything is in order, save any changes you have made, and choose to download, print, or share the form as needed.

Get started now by completing your Member Appeal Request Form online.