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
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?
Date of Service(s)
Provider Name
Claim Number(s)
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
a grievance, the Wellmark Civil Rights Coordinator is available to
available at, 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 
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TTY: 888-781-4262).
oder (TTY: 888-781-4262).
, ພາສາລາວ
: ພວກເຮ
. (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; 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TTY: 888-781-4262󰉦󰉆󰉆
ማሳሰቢያ፦ አማርኛ የሚናሩ ከሆነ፣ የቋንቋ እገዛ አልግቶች፣ ከክያ ነፃ፣
ያገኛሉ። 800-524-9242 ወይም (TTY: 888-781-4262) ደውለው ያነን።
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.
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)
and Wellmark Blue Cross and Blue Shield of South Dakota are independent licensees of the Blue Cross and Blue Shield Association.
09/16 A