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:
ID Number:
Patient Account Number:
Claim Information:
Patient Name:
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.
Supplemental Documentation:
Remittance Advice Spreadsheet Refund Medical Records
Other (describe):
Contact Information:
Requester: Date:
Individual requesting appeal Date of appeal request
Contact Number:
Phone, fax or email should be supplied for entity requesting appeal
Mailing address for response
Total number of pages: