Request for an Appeal or Redetermination

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

1 Please enter your information below.

2 Please confirm the form data is correct and click submit.

Member's Information
Name*
First Last
Date of Birth*
MM
DD
YYYY
Member's plan ID*
Requestor's Information
Complete this section only if the person making the request is not the member.
Name
First Last
Your relationship to the member
Address
Street Address City State ZIP / Postal Code
Phone
Type of Appeal or Redetermination
Please choose one:*
- I would like coverage for a service that has been denied.
- I would like payment for a claim that has been denied.
- I would like coverage for a drug that has been denied.
Additional information we should consider:
Email: (Optional) Please enter your email address below to receive a confirmation of your online request.
Enter Email Confirm Email

Member's Information