Fill - Free fillable APPEAL FORM PLEASE PRINT OR TYPE ALL INFORMATION PDF form

APPEAL FORM

PLEASE PRINT OR TYPE ALL INFORMATION

This form is to be completed by you, as a covered member, or your authorized representative, if you have designated one, if you

disagree with a beneﬁt determination and request a review of a claim for beneﬁts.

Member Information

Member Name: Identiﬁcation Number (from your ID card):

Patient Name:

Mailing Address:

Telephone Number:

Requester Information

If you are requesting an appeal on behalf of the member, an Appointment of Authorized Representative Form must be completed

and either be submitted with this form or on ﬁle with Wellmark. A member may appoint only one authorized representative at a

time.

This appeal is being requested by (Full Name):

Mailing Address:

Telephone Number:

Relationship to Member:

Claim Information (found on the front of Explanation of Health Care Beneﬁts or letter of denial or reduction)

Has the service in question already been provided?

 Yes

Date of Service(s)

Provider Name

Claim Number(s)

 No

Date of denial_____/_____/_____

Provider Name

Please provide an explanation of your appeal and attach any and all additional documentation that may assist us in our review.

Include what action you would like to see taken and use separate sheets if additional space is necessary. This appeal must be ﬁled

within 180 days of the date on the Explanation of Health Care Beneﬁts or letter of denial or reduction. You will receive a written

response to your request within the time required by law.

Are there documents attached? (Please retain a copy for yourself.) Yes No

Signature: Date:_____/_____/_____

Mail to:

Wellmark Blue Cross and Blue Shield

Special Inquires, Station 5W189

PO Box 9232

Des Moines, IA 50306-9232

Fax: 515-376-9073

C-53158 8/17 AN-T

Required Federal Accessibility and

Nondiscrimination Notice

Discrimination is against the law

Wellmark complies with applicable federal civil rights laws and

does not discriminate on the basis of race, color, national origin,

age, disability or sex. Wellmark does not exclude people or treat

them differently because of their race, color, national origin, age,

disability or sex.

Wellmark provides:

• Free aids and services to people with disabilities so they may

communicate effectively with us, such as:

• 

• Written information in other formats (large print, audio,

accessible electronic formats, other formats)

• Free language services to people whose primary language is

not English, such as:

• 

• Information written in other languages

If you need these services, call 800-524-9242.

If you believe that Wellmark has failed to provide these services or

discriminated in another way on the basis of race, color, national



Civil Rights Coordinator, 1331 Grand Avenue, Station 5W189,

Des Moines, IA 50309-2901, 515-376-4500, TTY 888-781-4262,

Fax 515-376-9073, Email CRC@Wellmark.com



a grievance, the Wellmark Civil Rights Coordinator is available to







available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail,



200 Independence Avenue S.W., Room 509F, HHH Building,

Washington DC 20201, 800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at 

index.html.

ATENCIÓN: Si habla español, los servicios de asistencia de idiomas

se encuentran disponibles gratuitamente para usted. Comuníquese al

800-524-9242 o al (TTY: 888-781-4262).

󲙸󵼾󰃷󱌒󲄬󱨸󴖄󱿾󴦪󴕭󰃩󱮡󰡼󰵿󵴠󴛉󰟊󱨸󱵠󰤫󴕽󶙙󰳟󰰹󲂝󰰱󴖇󱱸󱯣

800-524-9242󱮦󰃥󰶼󶡣󰞣󳡏󰃷888-781-4262󰃦



800-524-9242TTY: 888-781-4262).



800-524-9242

888-781-4262).



800-524-9242

oder (TTY: 888-781-4262).

:

.(888-781-4262:)800-524-9242

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. (TTY: 888-781-4262.)

󹦲󹠎󺘒󷸣󹙪󸨲󹅢󹝟󺘎󹎒󸍊󷵳󹝦󸯪󸦂󹙮󹙪󹩶󹞆󹇒󸻺󹍚󸨲󹠪󹝟󺘎󹎚

󹋎󹠾󹍫󸍾󸎚800-524-9242󸴾󸛆󸍊TTY: 888-781-4262󸴾󹟲󸤒󹚦󸠳󺘪

󹦲󹎣󹎒󹛚

󰉠󰍷󰏲󰉡󰉩

󰉤󰍺800-524-9242󰉆󰍷TTY: 888-781-4262



800 524 9242 (ou la

ligne ATS au 888 781 4262).



eegni Schprooch koschdefrei griege. Ruf 800-524-9242 odder (TTY:

888-781-4262) uff.



800-524-9242TTY: 888-781-4262)



may makukuha kang mga serbisyong tulong sa wika na walang bayad.

Makipag-ugnayan sa 800-524-9242 o (TTY: 888-781-4262).

w>'k;oh.ng= erh>uwdR unDusdm< usdmw>rRpXRw>zH;w>rRwz.< vXwb.vXmbl;vJ< td.vXe*D>vDRI qJ;usd;ql

800=524=9242 rhwrh> (TTY: 888=781=4262) wuh>I





800-524-9242

󰏱󰎋󰉩󰍠󰉡󰎋󰉩󰍩

󰍩󰉤󰉡800-524-9242TTY: 888-781-4262󰉦󰉆󰉆

ማሳሰቢያ፦ አማርኛ የሚናገሩ ከሆነ፣ የቋንቋ እገዛ አገልግሎቶች፣ ከክፍያ ነፃ፣

ያገኛሉ። በ 800-524-9242 ወይም (በTTY: 888-781-4262) ደውለው ያነጋግሩን።

HEETINA To a wolwa Fulfulde laabi walliinde dow wolde, naa e njobdi, ene

800-524-9242 malla (TTY: 888-781-4262).



gargaarsa afaanii, kaffaltii malee, isiniif ni jiru. 800-524-9242 yookin (TTY:

888-781-4262) quunnamaa.





800-524-9242888-781-4262).

Ge’: Diné k’ehj7 y1n7[ti’go n7k1 bizaad bee 1k1’ adoowo[, t’11 jiik’4,

n1h0l=. Koj8’ h0lne’ 800-524-9242 doodaii’ (TTY: 888-781-4262)



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