Pennsylvania Request For Hearing to Contest Fee Review Determination is a form used to appeal an insurance company's decision regarding a fee review. The form can be used if the insured believes that the insurance company has incorrectly determined the amount of a fee or if the insured disagrees with the company's decision to deny a fee. There are two types of Pennsylvania Request For Hearing to Contest Fee Review Determination: one for medical providers and one for non-medical providers. The medical provider form requires the insured to provide the name of the medical provider, the date of service, the fee charged, and the fee the insurance company approved. The non-medical provider form requires the insured to provide the name of the non-medical provider, the date of service, the fee charged, and the fee the insurance company approved. Both forms must be completed and submitted to the insurance company for review.