MF-AVA-0062-17
APPEAL FORM
If you disagree with our decision not to approve the service your doctor asked for, you can file an appeal using
this form within 60 days from the date of your denial letter.
Your provider, or any other person you choose, may appeal for you. If you ask someone to represent you, please
give them a signed letter of consent to include with the appeal.
MEMBER INFORMATION:
Member’s name: Anthem HealthKeepers Plus ID: Date of birth:
Address: City: State: ZIP code:
TYPE OF APPEAL REQUEST: ______Standard ______Urgent
An appeal may be handled urgently if you, your representative or your provider thinks:
The condition could seriously harm your life, health or ability to regain full function.
Would subject you to severe pain that can’t be managed without care or treatment by waiting for the appeal
to be resolved using standard appeal time frames.
PERSON MAKING APPEAL REQUEST: _________Member ________Provider ________Other
CONTACT INFORMATION:
Name of person requesting appeal for the member:
______________________________________________________________
Phone number: ________________________________ Fax number: ____________________________
Email: _______________________________________________________________________________
Requestor’s relationship to member:
______ Member/parent or legal guardian asking for appeal
______ Member’s representative asking for appeal for the member (must have member consent)
______ Provider asking for appeal for the member (must have member consent)
APPEAL DETAILS:
Name of servicing provider: __________________________________________________________________
Type of service or item to be given: ____________________________________________________________
Authorization reference number (if known):______________________________________________________
