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Request for an Appeal or Redetermination

This form is for 2023 requests only.

Submit 2024 or 2025 requests through your member website, by calling the Customer Service number on the back of your ID card, or by faxing or mailing using the contact information in your
Evidence of Coverage, Chapter 2.

Please complete the fields below to submit an online request for an appeal or redetermination. Fields marked with an asterisk (*) are required.

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