Appeal Request Form
This form is to be used when a provider is requesting a reconsideration of a previously adjudicated claim
but there is no additional or corrected data to be submitted.
Payer name and address, allow for formatting in window envelope for paper submission.
Billing Provider Information:
Patient Account Number:
Patient ID Number:
Date(s) of Service:
Payer Claim Number:
Property and Casualty or
Workers Compensation Claim Number:
Reason for Appeal Request:
Timely Filing Pricing Eligibility Medical Policy Code Review Other
Complete description of reason for claim appeal.
Remittance Advice Spreadsheet Refund Medical Records
Individual requesting appeal Date of appeal request
Phone, fax or email should be supplied for entity requesting appeal
Mailing address for response
Total number of pages: