Provider Appeal E-Form

Before completing this form for the Grievances and Appeal Unit (GAU), please consult the Claim Form Finder on

*Do not use this form for claim denials requiring Corrected Claims, Adjustments, or Reconsiderations*

If you have any 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.