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Get And Sign Instructions This Form Is To Be Completed By Providers To Request A Claim Appeal For Members Enrolled In A Plan

State Zip Code Provider Information TIN NPI Claim Information Provider Invoice Number Service From/To Date HCPCS/CPT and Modifiers Billed Claim Number Reconsideration Claim Information Date of Reconsideration Claim EOP Original Amount Billed Authorization Numbers s Reason For Reconsideration Claim Denial Please be specific when completing the description of dispute and the expected outcome including dollar amount if possible. Appeal Form Instructions This form is to be completed by providers to...

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