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.
- 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
Insurer Uploading Instructions
- 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