Provider Claim Dispute & Provider-initiated Appeal Form

*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

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.