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Web your request should include: Fax or mail the form to the contact information on the form. • request an appeal if you feel we didn’t cover or pay enough for a service or drug.

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Web complete the provider claims inquiry or dispute request form. Web this form will provide more information specific to the claim. Please complete the following information and return this form with supporting documentation to the applicable address listed on the corresponding appeal. You can find additional fep.

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Web what to include in your written request for a claim denial appeal or payment dispute. Use this form when a claim is finalized but you disagree with the outcome. Web filing a medical appeal. Web provider dispute form including reason for dispute;

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