Appeal a Denied Claim
There may be times when you’re not sure about a coverage decision and want to talk to us about it. We’re here to help. You can reach us by calling the Customer Service number on the front page of your Explanation of Benefits (EOB).
In some cases, you may just need clarity on why we processed a claim a certain way. Other times, you may want for us to reconsider a coverage decision. We can help talk you through your EOB, as well as your appeal rights and steps to take to start the appeal process.
The appeal process
You have the right to appeal a denied claim. To do so, you must submit a written request within 180 days from the date on your EOB. You can file the appeal yourself, or someone can file it on your behalf.
Your request should include the following information:
- Name and ID number
- Patient name
- Claim number
- Name of person filing appeal
- Whether the person filing the appeal is the covered person, patient or authorized representative
If someone else is filing your appeal for you, you must also sign a Designation of Authorized Representative to Appeal form.
Send your information to the mailing address listed in the appeal rights section of your EOB.
What happens next
We’ll re-review your claim within the standard timeframes, according to the terms of your benefit plan. If your situation is urgent, you may be eligible for a faster review.
Once we make our decision, we’ll notify you in writing. If we deny your appeal, the notice will include information on additional steps you may be able to take for further review.
Remember, you can always log into My Health Toolkit® to check the status of your claims or review EOBs. Sign into the secure site or use the mobile app – it’s available through the App Store or Google Play.
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