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.

1Please enter your information below.

2Please confirm the form data is correct and click submit.

Year the service or drug was provided
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.
Are you a member or a treating physician or appointed representative appealing on behalf of a member?*
If you are a provider and filing a medical appeal for yourself or a billing company filing a medical appeal on behalf of a provider, please fax your appeal to 504-849-6959. Note: Providers may submit medical claim adjustment requests through the Provider Portal.
Member's Information
Name*
First Last
Member's plan ID number*
Requestor's Information
Please note: If you are not the member or the treating physician, we will require certain documents before the appeal process can begin. A representative will contact you.
Name*
First Last
Your relationship to the member*
Billing company name*
Facility name*
Address*
Street address City State
ZIP / postal code*
Phone*
Name of treating provider*
Type of Appeal
Please look at the notice you received that said the health care or prescription drug request was denied. What is the name of the notice? It is listed at the top.*
Are you appealing a medical service or a drug?*
Has the service or drug been received?*
What is the name of the drug you are appealing?*
What is the claim number for the service or drug?*
What is the date the service or drug was provided?*
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.
What is the service or drug that was denied?*
What is the estimated date the service or drug will be provided?*
What is the name of the drug you are appealing?*
What are you asking the plan to do (what is the reason for your appeal)?*
What are you asking the plan to do (what is the reason for your appeal)?*
Additional Information
Additional information we should consider:
If you would like to submit documents to support your appeal—including an appointment of representation form if you are an appointed representative—please use the Select files button below.
Drop files here or

Accepted file types: doc, docx, Max. file size: 64 MB, Max. files: 3.
Please enter your email address to receive a confirmation email when this request is submitted.*
Enter Email Confirm Email

Request for an Appeal or Redetermination

This form is for 2023 requests only.

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

Member's Information

Requestor's Information

Type of Appeal

Additional Information

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