Grievance or appeal form

I want to report a grievance or appeal

1. Grievance details

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

*Check the one that applies

I am filing a grievance

I am filing an appeal

*Date Date of incident or notice of denial received

*Description

Please provide a description of your grievance 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 plan id no.

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

Yes, I am a requester

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: Expedited decision

If you or your provider believes our standard time frame of 15 business days to make a decision on your appeal will seriously jeopardize your life or health, you can ask for an expedited appeal.

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?

Enroll or renew

For members

Grievance or appeal form

I want to report a grievance or appeal

Important note: Expedited decision

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