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65 11/2005
PRACTITIONER/ PROVIDER
COMPLAINT AND APPEAL FORM
Date:
Submitted By:
Member Name:
Member ID:
Provider Name:
Tax ID:
Specialty:
Hospital Name:
Tax ID:
Date of service:
Procedure:
TYPE OF COMPLAINT OR APPEAL
Check only one:
• Reimbursement ____
• UCR Fee Allowance/Claims Edit System ___
• Timeliness of Filing ____
• Pre-Auth Not on File _____
• Other ____
• Medical Necessity ____
• Level of Care _____
• Length of Stay _____
• Complexity of Care ____
• Post-Service Review _____
REASON FOR COMPLAINT OR APPEAL (if more space is needed, please attach separate sheet):
FAX to 1-877-868-7950
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