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APPEAL/REVIEW FORM PLEASE PRINT OR TYPE ALL INFORMATION

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APPEAL/REVIEW 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 or request a review of a claim for benefits.
Member Information
Member Name:____________________________________ Identification Number (from your ID card):___________________________
If your appeal is related to an application submitted to Wellmark, please include the tracking and/or oer number from the letter you received
from Wellmark: _________________________________________________________________________________________________
Patient Name:_____________________________________ Telephone Number: ____________________________________________
Mailing Address:________________________________________________________________________________________________
Requester’s Information
If you are requesting an appeal on behalf of the member, a Personal Representative Appointment and Authorize
d to Release Protected Health
Information 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 the 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:
Date of declination/oer letter: _____________________________
C-3347 8/16 AN-T
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. Your request for a grievance 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
Member Appeals, Station 351
PO Box 5023
Sioux Falls, SD 57117-5023
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 ili (tekstualni
888-781-4262).

800-524-9242
oder (TTY: 888-781-4262).

.(888-781-4262 :  800-524-9242
ສ
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ວນເອ
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າໃຈໃສ
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, ພາສາລາວ ຖ
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800-524-9242 ຕ
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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)

and Wellmark Blue Cross and Blue Shield of South Dakota are independent licensees of the Blue Cross and Blue Shield Association.
M-2318376 08/16 A
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