Authorization appeal
Authorization details
Authorization or case ID number
Explanation of Benefits (EOB) denial code
A denial code is required to continue.
Cancel
Next
Please summarize the nature of this appeal
Summary
Summary is required
Back
Next
Your relationship to beneficiary
Self
Parent
Legal Guardian
Spouse
Appointed Representative
Attorney
Billing Service
Back
Next
Attorney information
Your Name
Your Name is required
Agency Name
Agency Name is required
Email
Email must include "@"
Phone Number
Phone Number is required
Street Address
Street Address is required
City
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
State is required
ZIP Code
Zip code must be 5 numbers
Back
Next
Billing service information
Company Name
Company Name is required
Email
Email must include "@"
Phone Number
Phone Number is required
Street Address
Street Address is required
City
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
State is required
ZIP Code
Zip code must be 5 numbers
Back
Next
Beneficiary information
First Name
First Name is required
Last Name
Last Name is required
Date of Birth
DoB must be before current date
DBN or SSN
DBN or SSN is required
Back
Next
Parent information
First Name
First Name is required
Last Name
Last Name is required
Email
Email must include "@"
Phone Number
Phone Number is required
Street Address
Street Address is required
City
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
State is required
ZIP Code
Zip code must be 5 numbers
Back
Next
Appointed representative information
First Name
First Name is required
Last Name
Last Name is required
Email
Email must include "@"
Phone Number
Phone Number is required
Street Address
Street Address is required
City
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
State is required
ZIP Code
Zip code must be 5 numbers
Back
Next
Legal guardian information
First Name
First Name is required
Last Name
Last Name is required
Email
Email must include "@"
Phone Number
Phone Number is required
Street Address
Street Address is required
City
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
State is required
ZIP Code
Zip code must be 5 numbers
Back
Next
Spouse information
First Name
First Name is required
Last Name
Last Name is required
Email
Email must include "@"
Phone Number
Phone Number is required
Street Address
Street Address is required
City
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
State is required
ZIP Code
Zip code must be 5 numbers
Back
Next
Your information
First Name
First Name is required
Last Name
Last Name is required
DBN or SSN
DBN or SSN is required
Date of Birth
DoB must be before current date
Phone Number
Phone Number is required
Email
Email must include "@"
Street Address
Street Address is required
City
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
State is required
ZIP Code
Zip code must be 5 numbers
Back
Next
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.
Close X
Having trouble?
File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
• Up to 10 files may be attached
• Total upload file size: max of 10 MB
Trouble adding attachments?
Add attachments
Back
Submit appeal
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.
Close X
Having trouble?
File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
• Up to 10 files may be attached
• Total upload file size: max of 10 MB
Trouble adding attachments?
Add attachments
Back
Submit appeal
Review and submit appeal request
Authorization or Case ID #
Reason for appeal
Billing Service
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.
Close X
Having trouble?
File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
• Up to 10 files may be attached
• Total upload file size: max of 10 MB
Trouble adding attachments?
Add attachments
Back
Submit appeal
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.
Close X
Having trouble?
File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
• Up to 10 files may be attached
• Total upload file size: max of 10 MB
Trouble adding attachments?
Add attachments
Back
Submit appeal
Review and submit appeal request
Authorization or Case ID #
Reason for appeal
Parent 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.
Close X
Having trouble?
File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
• Up to 10 files may be attached
• Total upload file size: max of 10 MB
Trouble adding attachments?
Add attachments
Back
Submit appeal
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.
Close X
Having trouble?
File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
• Up to 10 files may be attached
• Total upload file size: max of 10 MB
Trouble adding attachments?
Add attachments
Back
Submit appeal
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.
Close X
Having trouble?
File types accepted: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
• Up to 10 files may be attached
• Total upload file size: max of 10 MB
Trouble adding attachments?
Add attachments
Back
Submit appeal
Submitting your request...
Please wait
Loading...
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.
Submit another appeal
Home