Health Insurance Appeal Request Form PDF Details

Are you having difficulty getting an insurance company to cover a prescribed course of treatment or test? You may be able to initiate an administrative appeal with the help of a health insurance appeal request form. An effective appeal, though often complex and time-consuming, can be your best chance at obtaining coverage for a needed medical service – so it’s worth putting in the effort. In this blog post, we will discuss what exactly is involved in filing a health insurance appeal request and how doing so successfully can greatly increase your chances of obtaining covered care.

QuestionAnswer
Form NameHealth Insurance Appeal Request Form
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other nameshumana appeal form, appeal requestform, healthcare gov appeal form, forms appeal healthcare

Form Preview Example

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Appeal Request Form

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Health Insurance Marketplace

465 Industrial Blvd.

London, KY 40750-0061

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Requesting an appeal is time sensitive. Please review your eligibility notice to find appeals instructions specific to each person in your household, including the timeframe in which each person can request an appeal. \rxu#holjlelolw|#pd|#

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Please keep a copy of all forms for your records.

APPELLANT 1

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QUESTIONS? VISIT HealthCare.gov. OR, CALL 1-800-318-2596 (TTY: 1-855-889-4325). THE CALL IS FREE.

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List names of other household members who are filing an appeal using this form.

Name(s)*

APPELLANT 2:

APPELLANT 3:

APPELLANT 4:

*If there are additional people in your household who want to file an appeal using this form, please attach a separate piece of paper with their names.

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Explain the reason for your appeal.

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QUESTIONS? VISIT HealthCare.gov. OR, CALL 1-800-318-2596 (TTY: 1-855-889-4325). THE CALL IS FREE.

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Authorization to disclose federal tax and Social Security information for use during an appeal

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The Marketplace can’t disclose federal income tax information or income information from Social Security without your authorization. You give your authorization for this disclosure by signing on page 4.

QUESTIONS? VISIT HealthCare.gov. OR, CALL 1-800-318-2596 (TTY: 1-855-889-4325). THE CALL IS FREE.

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QUESTIONS? VISIT HealthCare.gov. OR, CALL 1-800-318-2596 (TTY: 1-855-889-4325). THE CALL IS FREE.

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Health Insurance Marketplace

465 Industrial Blvd.

London, KY 40750-0061

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Requesting an expedited appeal

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Health coverage during your appeal

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GO TO HealthCare.gov/can-i-appeal-a-marketplace-decision,

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Privacy and use of your information

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QUESTIONS? VISIT HealthCare.gov. OR, CALL 1-800-318-2596 (TTY: 1-855-889-4325). THE CALL IS FREE.

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QUESTIONS? VISIT HealthCare.gov. OR, CALL 1-800-318-2596 (TTY: 1-855-889-4325). THE CALL IS FREE.

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Assistance with completing this application

You can choose an authorized representative.

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Writing part 1 of insurance appeal form letter

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Step no. 2 in completing insurance appeal form letter

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insurance appeal form letter conclusion process explained (step 3)

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Explain the reason for your appeal, Explain the reason for your appeal, and Explain the reason for your appeal inside insurance appeal form letter

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QUESTIONS Visit HealthCaregov Or, QUESTIONS Visit HealthCaregov Or, and QUESTIONS Visit HealthCaregov Or of insurance appeal form letter

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