Welcome health insurers!

The following information is in regards to the requirements needed to complete a successful Health Care Appeal through our portal.

Make sure to include:

• Health Care Appeals Transmittal Form
• Provider Certification Form For Expedited Review
• Request for Appeal
  • The member’s or treating provider’s letter or form requesting the appeal.
• Insurer Decision
  • The utilization review agent’s or insurer’s decision, including a summary of applicable issues, relevant portions from the utilization review plan, and the criteria used and the clinical reasons for the claim decision.
• Policy/Contract
  • A copy of the insured’s complete policy, certificate, evidence of coverage or similar document.
• Medical Records
  • Medical records and supporting documentation used to render the claim decision.
•  Appeal Correspondence
  • Correspondence between the member/provider and the insurer involving the claim.

File Requirements: files need to be 10 MB or under in size

• Complete the Consumer Complaint form directly from the link provided below.
• COMPLAINANT: Enter YOURSELF as the Insurer contact person
• Relationship to Complainant: choose “Other”
• Insured’s Information: Enter member’s name and information
• Other Parties involved section: Enter provider(s) information 
• “Who is the Complaint Against” section: enter Insurer Name
• Enter other known information (e.g., claim number, policy number)
• Type of Insurance: select Group Health or Individual Health
• Reason for Complaint:  select Claim Denial
• Details and Supporting Documents: Include brief summary of appeal issue(s) 
  • NOTE:  If requesting expedited status, type “EXPEDITED” before entering summary of appeal.  
• After final submission notice, click YES for supporting documents to be added (disregard instructions to submit documents to [email protected]; any documents not submitted with form should be sent to [email protected]
• Choose YES to receive email confirmation
• After you click on Submit Complaint, you’ll get a confirmation screen with a Tracking Number that will be the Case Number
•  Just below will be a lightly lined box with “+Upload Attachment”
•  Click that box to upload documents
  •  NOTE:  each file needs to be 10 MG or under in size
  •  The system requires a description be provided for every file uploaded
    •  If uploading a zip file (recommended), simply say all appeal documents
    • If uploading individual documents, include description such as Policy, Request for Appeal, Acknowledgement Letter, Insurer Decision, etc.). 
    •  If uploading more than one file, click blue Upload button after each file, then go back and click again on “+Upload Attachment” to upload the next file