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. Request for an Appeal or Redetermination 1 Please enter your information below.2 Please confirm the form data is correct and click submit. Member's InformationName* First Last Date of Birth* MM DD YYYY Member's plan ID*Requestor's InformationComplete this section only if the person making the request is not the member.Name First Last Your relationship to the memberAddress Street Address City State ZIP / Postal Code PhoneType of Appeal or RedeterminationPlease 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 {all_fields} This iframe contains the logic required to handle Ajax powered Gravity Forms.
