Claim appeal

Appeal a denied claim

What do I need to submit a claim appeal?

Review the checklist below before completing an appeal to ensure a successful submission and timely processing. Any incorrect or missing information may cause a delay in processing your appeal. This checklist includes:

Claim Number (Claims Appeals)

Must be nine to 13 characters long
Can be a combination of alpha and numeric characters
Can be located through your beneficiary self-service dashboard or in the upper right or left-hand corner of your EOB.

Claim Denial Code (Claims Appeals)

Must be a three to five digit number
Located on your EOB near service description

Date of Service (Claims Appeals)

Must be a valid date that is today or earlier
Future dates are not allowed

Contact information (Address, Phone, Email)

For submitter
For beneficiary

Beneficiary Information

Sponsor’s Benefits Number or Social Security Number
Date of Birth

Supporting documentation

Documentation to support the appeal
Appointment of Representative (AOR) form
Accepted files: pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, .txt
NO bank account or credit card information will be accepted

How long does it take to complete the form?

Five to 10 minutes (if you have everything from the checklist).

How long does it take to process my appeal?

Once the appeal is submitted, you will receive a tracking number for your records. You will receive a response by mail within 60 days of submission.

I have read the checklist and have what I need to complete the appeal

Claim details

Claim number (claims appeals)

Must be nine to 13 characters long
Can be a combination of alpha and numeric characters
Found on your beneficiary self-service dashboard or in the upper-right or left-hand corner of your EOB

Claim denial code (claims appeals)

Must be a three-to-five-digit number
Located on your EOB near service description or at the end of the remarks section

Date of Service (claims appeals)

Must be a valid date that is today or earlier
Future dates are not allowed

Summary

Relationship

Information

Review

Claim details

Summary

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

Relationship

Information

Review

Claim details

Summary

Relationship

If you are submitting an appeal as an appointed representative (e.g. parent or legal representative), you must first have the beneficiary complete and sign an AOR form. You must upload this form at the end of the appeal process.

Information

Review

Claim details

Summary

Relationship

Information

The sponsor's DBN is an 11-digit number found on the back of the beneficiary ID card. If the sponsor's DBN isn't available, you can use the sponsor's Social Security Number.
The DBN 11-digit number must include two digits following the dash.

Review

Claim details

Summary

Relationship

Information

Review

Please review your appeal detail before you submit. Any incorrect or missing information may cause a delay in processing your appeal.

Upload any supporting documentation including the AOR form if you are submitting for anyone other than yourself.

Submit all documents pertaining to this appeal together.
Accepted file types are: .pdf, .docx, .bmp, .jpeg, .jpg, .png, .tiff, and .txt.
Do not submit any bank account or credit card information.

Claim details

Summary

Relationship

Information

Review

Claim details

Claim number

A Claim number is required

Explanation of Benefits (EOB) denial code

Valid EOB is required.

Date of Service

Valid Date of Service is required.

Please summarize the nature of this appeal

Summary

Summary is required

Your relationship to beneficiary

Attorney information

Your Name

Your Name is required

Agency Name

Agency Name is required

Email must include "@"

Phone Number

Phone Number is required

Street Address

Street Address is required

City

State

State is required

ZIP Code

Zip code must be 5 numbers

Billing Service information

Company Name

Company Name is required

Email must include "@"

Phone Number

Phone Number is required

Street Address

Street Address is required

City

State

State is required

ZIP Code

Zip code must be 5 numbers

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

Parent of a minor child information

First Name

First Name is required

Last Name

Last Name is required

Email must include "@"

Phone Number

Phone Number is required

Street Address

Street Address is required

City

State

State is required

ZIP Code

Zip code must be 5 numbers

Appointed representative information

First Name

First Name is required

Last Name

Last Name is required

Email must include "@"

Phone Number

Phone Number is required

Street Address

Street Address is required

City

State

State is required

ZIP Code

Zip code must be 5 numbers

Legal guardian information

First Name

First Name is required

Last Name

Last Name is required

Email must include "@"

Phone Number

Phone Number is required

Street Address

Street Address is required

City

State

State is required

ZIP Code

Zip code must be 5 numbers

Non-Network Provider information

First Name

First Name is required

Last Name

Last Name is required

Email must include "@"

Phone Number

Phone Number is required

Street Address

Street Address is required

City

State

State is required

ZIP Code

Zip code must be 5 numbers

Spouse information

First Name

First Name is required

Last Name

Last Name is required

Email must include "@"

Phone Number

Phone Number is required

Street Address

Street Address is required

City

State

State is required

ZIP Code

Zip code must be 5 numbers

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 must include "@"

Street Address

Street Address is required

City

State

State is required

ZIP Code

Zip code must be 5 numbers

Review and submit appeal request

Claim #

EOB denial code

Date of Service

Reason for appeal

Appointed representative information

Name

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?

Review and submit appeal request

Claim #

EOB denial code

Date of Service

Reason for appeal

Attorney information

Name

Agency Name

Lawyers of America

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

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?

Review and submit appeal request

Claim #

EOB denial code

Date of Service

Reason for appeal

Billing Service information

Company Name

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

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?

Review and submit appeal request

Claim #

EOB denial code

Date of Service

Reason for appeal

Legal guardian information

Name

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

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?

Review and submit appeal request

Claim #

EOB denial code

Date of Service

Reason for appeal

Non-Network Provider information

Name

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

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?

Review and submit appeal request

Claim #

EOB denial code

Date of Service

Reason for appeal

Parent of a minor child information

Name

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

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?

Review and submit appeal request

Claim #

EOB denial code

Date of Service

Reason for appeal

Your information

Name

DBN or SSN

Date of birth

Phone number

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

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?

Review and submit appeal request

Claim #

EOB denial code

Date of Service

Reason for appeal

Spouse information

Name

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

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?

Submitting your request...

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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.