Appeal Portal

Authorization details

Case Identification Number

Must be 11 characters long
Numbers only
No special numbers

Can’t find your number? Log in to beneficiary self-service to find it on the dashboard, or on the authorization denial letter.

Summary

Relationship

Information

Review

Authorization details

Authorization or case ID number

Authorization details

Summary

Please describe the item or service you are appealing, including the specific matter with which you disagree.

Relationship

Information

Review

Please summarize the nature of this appeal

Summary

Authorization details

Summary

Relationship

If you are submitting an appeal for anyone other than yourself, complete the Appointment of Representative form. Have the beneficiary sign it. You will need to upload the AOR to complete the appeal submission.

Download the AOR form.

Information

Review

Your relationship to beneficiary

Authorization appeal

Summary

Relationship

Information

What's the Department of Defense Benefits Number?

The DBN is an eleven-digit number found on the back of the beneficiary’s ID card. The number includes the two digits following the dash.

If you can’t find the DBN, you can use the sponsor’s social security number.

Review

Attorney information

Your Name

Agency Name

Email

Phone Number

Street Address

City

State

ZIP Code

Authorization appeal

Summary

Relationship

Information

What's the Department of Defense Benefits Number?

The DBN is an eleven-digit number found on the back of the beneficiary’s ID card. The number includes the two digits following the dash.

If you can’t find the DBN, you can use the sponsor’s social security number.

Review

Billing Service information

Company Name

Email

Phone Number

Street Address

City

State

ZIP Code

Authorization appeal

Summary

Relationship

Information

What's the Department of Defense Benefits Number?

The DBN is an eleven-digit number found on the back of the beneficiary’s ID card. The number includes the two digits following the dash.

If you can’t find the DBN, you can use the sponsor’s social security number.

Review

Beneficiary information

First Name

Last Name

Date of Birth

DBN or SSN

Authorization appeal

Summary

Relationship

Information

What's the Department of Defense Benefits Number?

The DBN is an eleven-digit number found on the back of the beneficiary’s ID card. The number includes the two digits following the dash.

If you can’t find the DBN, you can use the sponsor’s social security number.

Review

Parent of a minor child information

First Name

Last Name

Email

Phone Number

Street Address

City

State

ZIP Code

Authorization appeal

Summary

Relationship

Information

What's the Department of Defense Benefits Number?

The DBN is an eleven-digit number found on the back of the beneficiary’s ID card. The number includes the two digits following the dash.

If you can’t find the DBN, you can use the sponsor’s social security number.

Review

Non-Network Provider information

First Name

Last Name

Email

Phone Number

Street Address

City

State

ZIP Code

Authorization appeal

Summary

Relationship

Information

What's the Department of Defense Benefits Number?

The DBN is an eleven-digit number found on the back of the beneficiary’s ID card. The number includes the two digits following the dash.

If you can’t find the DBN, you can use the sponsor’s social security number.

Review

Appointed representative information

First Name

Last Name

Email

Phone Number

Street Address

City

State

ZIP Code

Authorization appeal

Summary

Relationship

Information

What's the Department of Defense Benefits Number?

The DBN is an eleven-digit number found on the back of the beneficiary’s ID card. The number includes the two digits following the dash.

If you can’t find the DBN, you can use the sponsor’s social security number.

Review

Legal guardian information

First Name

Last Name

Email

Phone Number

Street Address

City

State

ZIP Code

Authorization appeal

Summary

Relationship

Information

What's the Department of Defense Benefits Number?

The DBN is an eleven-digit number found on the back of the beneficiary’s ID card. The number includes the two digits following the dash.

If you can’t find the DBN, you can use the sponsor’s social security number.

Review

Spouse information

First Name

Last Name

Email

Phone Number

Street Address

City

State

ZIP Code

Authorization appeal

Summary

Relationship

Information

What's the Department of Defense Benefits Number?

The DBN is an eleven-digit number found on the back of the beneficiary’s ID card. The number includes the two digits following the dash.

If you can’t find the DBN, you can use the sponsor’s social security number.

Review

Your information

First Name

Last Name

DBN or SSN

Date of Birth

Phone Number

Email

Street Address

City

State

ZIP Code

Authorization appeal

Summary

Relationship

Information

Review

Please review your appeal details before you submit it. Any incorrect or missing information may delay our review of your appeal.

If you are submitting an appeal for someone else, upload supporting documentation, including the AOR form.

Follow these step to upload documents:

Make sure all documents pertaining to this appeal are submitted together.
Confirm the file type: pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, or .txt.

Do not submit bank account or credit card information.

Review and submit appeal request

Authorization or Case ID #

Reason for appeal

Appointed representative information

Name

Phone number

Email

Address

Beneficiary information

Name

Date of birth

DBN or SSN

Attachments

Please attach any documentation that may be required for a complete review of the denied care.

Something is incorrect with the file(s) you are trying to attach

Ensure your attachments meet the following:

File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
Max number of files allowed: 10
Max total upload file size: 10MB

I acknowledge that I have not attached any full bank account or credit card numbers. If submitted, I understand that anything with full bank account or credit card numbers will be removed from our system and will not be processed. Payment information should only be submitted using our secure payment options.

Trouble adding attachments?

Authorization appeal

Summary

Relationship

Information

Review

Please review your appeal details before you submit it. Any incorrect or missing information may delay our review of your appeal.

If you are submitting an appeal for someone else, upload supporting documentation, including the AOR form.

Follow these step to upload documents:

Make sure all documents pertaining to this appeal are submitted together.
Confirm the file type: pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, or .txt.

Do not submit bank account or credit card information.

Review and submit appeal request

Authorization or Case ID #

Reason for appeal

Attorney information

Name

Agency Name

Lawyers of America

Email

Phone number

Address

Beneficiary information

Name

Date of birth

DBN or SSN

Attachments

Please attach any documentation that may be required for a complete review of the denied care.

Something is incorrect with the file(s) you are trying to attach

Ensure your attachments meet the following:

File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
Max number of files allowed: 10
Max total upload file size: 10MB

I acknowledge that I have not attached any full bank account or credit card numbers. If submitted, I understand that anything with full bank account or credit card numbers will be removed from our system and will not be processed. Payment information should only be submitted using our secure payment options.

Trouble adding attachments?

Authorization appeal

Summary

Relationship

Information

Review

Please review your appeal details before you submit it. Any incorrect or missing information may delay our review of your appeal.

If you are submitting an appeal for someone else, upload supporting documentation, including the AOR form.

Follow these step to upload documents:

Make sure all documents pertaining to this appeal are submitted together.
Confirm the file type: pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, or .txt.

Do not submit bank account or credit card information.

Review and submit appeal request

Authorization or Case ID #

Reason for appeal

Billing Service information

Company Name

Email

Phone number

Address

Beneficiary information

Name

Date of birth

DBN or SSN

Attachments

Please attach any documentation that may be required for a complete review of the denied care.

Something is incorrect with the file(s) you are trying to attach

Ensure your attachments meet the following:

File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
Max number of files allowed: 10
Max total upload file size: 10MB

I acknowledge that I have not attached any full bank account or credit card numbers. If submitted, I understand that anything with full bank account or credit card numbers will be removed from our system and will not be processed. Payment information should only be submitted using our secure payment options.

Trouble adding attachments?

Authorization appeal

Summary

Relationship

Information

Review

Please review your appeal details before you submit it. Any incorrect or missing information may delay our review of your appeal.

If you are submitting an appeal for someone else, upload supporting documentation, including the AOR form.

Follow these step to upload documents:

Make sure all documents pertaining to this appeal are submitted together.
Confirm the file type: pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, or .txt.

Do not submit bank account or credit card information.

Review and submit appeal request

Authorization or Case ID #

Reason for appeal

Legal guardian information

Name

Phone number

Email

Address

Beneficiary information

Name

Date of birth

DBN or SSN

Attachments

Please attach any documentation that may be required for a complete review of the denied care.

Something is incorrect with the file(s) you are trying to attach

Ensure your attachments meet the following:

File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
Max number of files allowed: 10
Max total upload file size: 10MB

I acknowledge that I have not attached any full bank account or credit card numbers. If submitted, I understand that anything with full bank account or credit card numbers will be removed from our system and will not be processed. Payment information should only be submitted using our secure payment options.

Trouble adding attachments?

Authorization appeal

Summary

Relationship

Information

Review

Please review your appeal details before you submit it. Any incorrect or missing information may delay our review of your appeal.

If you are submitting an appeal for someone else, upload supporting documentation, including the AOR form.

Follow these step to upload documents:

Make sure all documents pertaining to this appeal are submitted together.
Confirm the file type: pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, or .txt.

Do not submit bank account or credit card information.

Review and submit appeal request

Authorization or Case ID #

Reason for appeal

Non-Network Provider information

Name

Phone number

Email

Address

Beneficiary information

Name

Date of birth

DBN or SSN

Attachments

Please attach any documentation that may be required for a complete review of the denied care.

Something is incorrect with the file(s) you are trying to attach

Ensure your attachments meet the following:

File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
Max number of files allowed: 10
Max total upload file size: 10MB

I acknowledge that I have not attached any full bank account or credit card numbers. If submitted, I understand that anything with full bank account or credit card numbers will be removed from our system and will not be processed. Payment information should only be submitted using our secure payment options.

Trouble adding attachments?

Authorization appeal

Summary

Relationship

Information

Review

Please review your appeal details before you submit it. Any incorrect or missing information may delay our review of your appeal.

If you are submitting an appeal for someone else, upload supporting documentation, including the AOR form.

Follow these step to upload documents:

Make sure all documents pertaining to this appeal are submitted together.
Confirm the file type: pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, or .txt.

Do not submit bank account or credit card information.

Review and submit appeal request

Authorization or Case ID #

Reason for appeal

Parent of a minor child information

Name

Phone number

Email

Address

Beneficiary information

Name

Date of birth

DBN or SSN

Attachments

Please attach any documentation that may be required for a complete review of the denied care.

Something is incorrect with the file(s) you are trying to attach

Ensure your attachments meet the following:

File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
Max number of files allowed: 10
Max total upload file size: 10MB

I acknowledge that I have not attached any full bank account or credit card numbers. If submitted, I understand that anything with full bank account or credit card numbers will be removed from our system and will not be processed. Payment information should only be submitted using our secure payment options.

Trouble adding attachments?

Authorization appeal

Summary

Relationship

Information

Review

Please review your appeal details before you submit it. Any incorrect or missing information may delay our review of your appeal.

If you are submitting an appeal for someone else, upload supporting documentation, including the AOR form.

Follow these step to upload documents:

Make sure all documents pertaining to this appeal are submitted together.
Confirm the file type: pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, or .txt.

Do not submit bank account or credit card information.

Review and submit appeal request

Authorization or Case ID #

Reason for appeal

Your information

Name

DBN or SSN

Date of birth

Phone number

Email

Address

Attachments

Please attach any documentation that may be required for a complete review of the denied care.

Something is incorrect with the file(s) you are trying to attach

Ensure your attachments meet the following:

File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
Max number of files allowed: 10
Max total upload file size: 10MB

I acknowledge that I have not attached any full bank account or credit card numbers. If submitted, I understand that anything with full bank account or credit card numbers will be removed from our system and will not be processed. Payment information should only be submitted using our secure payment options.

Trouble adding attachments?

Authorization appeal

Summary

Relationship

Information

Review

Please review your appeal details before you submit it. Any incorrect or missing information may delay our review of your appeal.

If you are submitting an appeal for someone else, upload supporting documentation, including the AOR form.

Follow these step to upload documents:

Make sure all documents pertaining to this appeal are submitted together.
Confirm the file type: pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, or .txt.

Do not submit bank account or credit card information.

Review and submit appeal request

Authorization or Case ID #

Reason for appeal

Spouse information

Name

Phone number

Email

Address

Beneficiary information

Name

Date of birth

DBN or SSN

Attachments

Please attach any documentation that may be required for a complete review of the denied care.

Something is incorrect with the file(s) you are trying to attach

Ensure your attachments meet the following:

File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
Max number of files allowed: 10
Max total upload file size: 10MB

I acknowledge that I have not attached any full bank account or credit card numbers. If submitted, I understand that anything with full bank account or credit card numbers will be removed from our system and will not be processed. Payment information should only be submitted using our secure payment options.

Trouble adding attachments?

Authorization appeal

Summary

Relationship

Information

Review

Submitting your request...

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Authorization appeal

Summary

Relationship

Information

Review

Your appeal request has been submitted

Appeal submission #

Save this number for your records. You will receive a response by mail within 60 days of submission.

Authorization appeal

Authorization details

A denial code is required to continue.

Please summarize the nature of this appeal

Summary is required

Your relationship to beneficiary

Attorney information

Your Name is required

Agency Name is required

Email must include "@"

Phone Number is required

Street Address is required

State is required

Zip code must be 5 numbers

Billing Service information

Company Name is required

Email must include "@"

Phone Number is required

Street Address is required

State is required

Zip code must be 5 numbers

Beneficiary information

First Name is required

Last Name is required

DoB must be before current date

DBN or SSN is required

Parent of a minor child information

First Name is required

Last Name is required

Email must include "@"

Phone Number is required

Street Address is required

State is required

Zip code must be 5 numbers

Non-Network Provider information

First Name is required

Last Name is required

Email must include "@"

Phone Number is required

Street Address is required

State is required

Zip code must be 5 numbers

Appointed representative information

First Name is required

Last Name is required

Email must include "@"

Phone Number is required

Street Address is required

State is required

Zip code must be 5 numbers

Legal guardian information

First Name is required

Last Name is required

Email must include "@"

Phone Number is required

Street Address is required

State is required

Zip code must be 5 numbers

Spouse information

First Name is required

Last Name is required

Email must include "@"

Phone Number is required

Street Address is required

State is required

Zip code must be 5 numbers

Your information

First Name is required

Last Name is required

DBN or SSN is required

DoB must be before current date

Phone Number is required

Email must include "@"

Street Address is required

State is required

Zip code must be 5 numbers

Review and submit appeal request

Something is incorrect with the file(s) you are trying to attach

Review and submit appeal request

Something is incorrect with the file(s) you are trying to attach