Common use of How to File an Appeal Clause in Contracts

How to File an Appeal. If you disagree with either a pre-service request for Benefits determination, post-service claim determination or a rescission of coverage determination, you can contact us in writing to formally request an appeal. • Your request for an appeal should include: • The patient's name and the identification number from the ID card. • The date(s) of medical service(s). • The provider's name. • The reason you believe the claim should be paid. • Any documentation or other written information to support your request for claim payment. Your first appeal request must be submitted to us within 180 days after you receive the denial of a pre- service request for Benefits or the claim denial.

How to File an Appeal. If you disagree with either a pre-service request for Benefits determination, post-service claim determination or a rescission of coverage determination, you can contact us in writing to formally request an appeal. •  Your request for an appeal should include: •  The patient's name and the identification number from the ID card. •  The date(s) of medical service(s). •  The provider's name. •  The reason you believe the claim should be paid. •  Any documentation or other written information to support your request for claim payment. Your first appeal request must be submitted to us within 180 days after you receive the denial of a pre- service request for Benefits or the claim denial.