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. 1Please enter your information below.2Please confirm the form data is correct and click submit. Are you a member or a treating physician or appointed representative appealing on behalf of a member?*Select OneI am a memberI am a treating physician or appointed representative appealing on behalf of a memberI am not appealing on behalf of a memberIf you are a provider and filing a medical appeal for yourself or a billing company filing a medical appeal on behalf of a provider, please fax your appeal to 504-849-6959. Note: Providers may submit medical claim adjustment requests through the Provider Portal.Member's InformationName* First Last Member's plan ID number* Requestor's InformationPlease note: If you are not the member or the treating physician, we will require certain documents before the appeal process can begin. A representative will contact you.Name* First Last Your relationship to the member*Select onePhysician's officeFamily member or caregiverBilling company name* Facility name* Address* Street address City State ZIP / postal code* Phone*Name of treating provider* Type of AppealPlease look at the notice you received that said the health care or prescription drug request was denied. What is the name of the notice? It is listed at the top.*Select OneNotice of Denial of Medical CoverageNotice of Denial of Medicare Prescription Drug CoverageMonthly Prescription Drug SummaryClaims Report for Medical and Hospital ClaimsI don't have a noticeAre you appealing a medical service or a drug?*Select OneMedical serviceDrugHas the service or drug been received?*Select OneYesNoWhat is the name of the drug you are appealing?* What is the claim number for the service or drug?* What is the date the service or drug was provided?* What is the service or drug that was denied?* What is the estimated date the service or drug will be provided?* What is the name of the drug you are appealing?* What are you asking the plan to do (what is the reason for your appeal)?*What are you asking the plan to do (what is the reason for your appeal)?*Additional InformationAdditional information we should consider:If you would like to submit documents to support your appeal—including an appointment of representation form if you are an appointed representative—please use the Select files button below. Drop files here or Select files Accepted file types: doc, docx, Max. file size: 64 MB, Max. files: 3. Please enter your email address if you would like us to send you a confirmation email when this request is submitted. Enter Email Confirm Email {all_fields}EmailThis field is for validation purposes and should be left unchanged.
