Complaint or appeal form

I want to report a complaint or appeal

1. Complaint or appeal details

Please provide details of the complaint or appeal in the fields below. All fields marked with an asterisk (*) are required.

*Check the one that applies

I am filing a complaint

I am filing an appeal

*Date Date of incident or notice of denial received

*Description

Full details of your complaint or appeal

2. Member information

Please provide the following information. All fields marked with an asterisk (*) are required.

*Name

*Date of birth

*Address 1

Address 2

*City

*State

*Zip Code Example: 12345

*Phone Number Example: 1234567890

*Member ID

*Are you filing this complaint or appeal on behalf of someone else?

Yes, I am an appointed representative

No, I am the member

Please provide documentation showing the authority to represent the member if it was not submitted previously. Representatives include family members, friends, caregivers or providers who the member authorized in writing or others legally able to act on behalf of the member, such as someone who holds power of attorney or the member’s legal guardian. You can mail, fax or email the documentation directly to us. You can find all our contact information on our “Contact us” page.

3. Your information

Please provide your information in the following fields. All fields marked with an asterisk (*) are required.

*Name

*Relationship Your relationship to member

*Date of birth

*Address 1

Address 2

*City

*State

*Zip Code Example: 12345

*Phone Number Example: 1234567890

Important note:

fast decision

If you or your provider believes that waiting 30 days for a standard decision could seriously harm your life, health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your provider indicates that waiting 30 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your provider’s support for an expedited appeal, we will decide if your case requires a fast decision.

Check this box if you believe you need a decision within 72 hours. If you have a supporting statement from your provider, you can mail, fax or email the documentation directly to us. You can find all our contact information on our “Contact us” page.

*Signature

*Date Today's date

*Signature Type

What's covered?

For members

Complaint or appeal form

I want to report a complaint or appeal

Important note:

fast decision