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Request for an Appeal or Redetermination

This form is for 2023 requests only.
To submit an appeal or redetermination for 2024, you can do so through your member website.

Please complete the fields below to submit an online request for an appeal or redetermination. Fields marked with an asterisk (*) are required.  

If you need assistance submitting this form, call provider services at 504-849-4688 or 877-346-5703.


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