Claims Appeal

Claims Appeal
Submission Instructions:

You may only submit claims appeals for claims marked as paid. Appeals submitted for claims in a pending or pay status will be rejected. You can track claim status in JoinHealth.
Did any money apply towards your deductible, out-of-pocket maximum, or copay?
Please call Customer Service for assistance.

Was the claim denied due to missing or incorrect information (such as billing or coding errors)?
Your provider must call Customer Service or submit a corrected claim.

Was the claim denied because the provider was out-of-network, or authorization was required but not on file?
Please call Customer Service to confirm benefit requirements and options.

Was the claim denied for one of the appeal-eligible reasons listed in the dropdown menu? Please select the denial code listed on your EOB.
Please call Customer Service for further review.
You must attach medical records to appeal this claim.
You must attach nursing treatment notes to appeal this claim.
You must attach an attestation document from your healthcare provider to appeal this claim.
You must attach provider treatment notes to appeal this claim.

Submission Instructions:

You may only submit claims appeals for claims marked as paid. Appeals submitted for claims in a pending or pay status will be rejected. You can track claim status in JoinHealth.

Membership Information: Use the Member ID number and Group Number found on the front of your membership card.
Patient Information
Member Name*

First NameLast Name
Patient Name (if different)

First NameLast Name
Patient ID*
Group Number*
Please enter your 5 digit group number as shown on your ID card.
Group Number (First Number)
Claim Information
PaidPendingPay
An appeal cannot be submitted until a claim has reached a paid status. You can track the status of claims in JoinHealth.
Claim Number
Provider Name
Date of Service

MonthDayYear
Total Charge Amount
Reason for Appeal (If this appeal impacts multiple claims, please list each claim number below along with the reason)
Supporting Documents (Please attach a copy of your EOB, a letter explaining why you are appealing this claim, and any additional information you have regarding this appeal, such as medical records)*

Cancelof
Should be Empty:

Patient Information