*Do not use this form for claim denials requiring Corrected Claims, Adjustments, or Reconsiderations*
Before completing this form for the Grievances and Appeal Unit (GAU), please consult the Claim Form Finder on NHPRI.org
If you have questions, please call Provider Services at 1-800-963-1001
Please note: All fields are required and must include attachment. One e-Form per appeal per member.