Use this form to submit an appeal on a claim. Make sure you have you have a copy of the claim or the Explanation of Benefits (EOB) to include with your submission.
Plan Members must complete this information to release PHI to a provider or other party.
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
In order to comply with the Transparency in Coverage legislation, insurance plans are required to make available machine-readable files for in-network rates (for providers in the plan’s network) and for out of network rates (for providers not in the plan’s network). Select the desired file for more information. Please note: These files contain a large amount of data and may require several minutes to download/open.