Provider Appeal Form – 1st Level of Appeal

This form is for providers to request an appeal after they receive an adverse coverage decision (PA, Claim). Supporting documentation must be uploaded; this may include, but is not limited to: medication history, diagnostic workup, lab results, chart notes, etc.

Who May Request a Level 1 Appeal

Part C - Standard Pre-Service/Expedited Pre-Service
The enrollee’s treating physician acting on behalf of the enrollee or staff of physician’s office acting on said physician’s behalf (e.g., request is on said physician’s letterhead or otherwise indicates staff is working under the direction of the provider).

Standard Payment Reconsideration
Non-contract provider (see §50.1.1 for non-contract provider payment appeals).

Part D - Standard or Expedited Redetermination
An enrollee’s prescribing physician, another prescriber acting on behalf of the enrollee, or the staff of a physician’s office acting on a physician’s behalf (e.g., request is on the office’s letterhead).

Important Note for Expedited Decisions

Medical Item/Service - If you believe that waiting 30 days for a standard decision could seriously harm your patient’s life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. You cannot request an expedited appeal if you are asking us to pay for a service/item the member has already received.

Medicare Prescription Drug - If you believe that waiting 7 days for a standard prescription drug decision could seriously harm your patient’s life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision.

Are you requesting for a decision within 72 hours?

Expedited appeal requests can also be made by phone at: 1-877-672-8620 (TTY 711), daily from 8 a.m. to 5 p.m. PST.

Provider/Physician Information

Provider Full Name *

Street Address *

Street Address Line 2

City *

Zip Code *

Phone Number *

Fax # *

Email *

Service/Medication Requested *

Quantity

Diagnosis *

Reason for Appeal *

Claim denied
Authorization does not cover services rendered
Prior Authorization denied

Date of Service (if applicable)

Date of Decision Notice

Patient Information

Patient Full Name *

Patient Member ID # *

Date of Birth *

PA Case #, Reference #, or Rx# *

Please indicate why the service/medication is medically necessary for the patient *

Upload any supporting documentation

Requestor's Full Name *

Provider Appeal Form – 1st Level of Appeal

Company

Resources

Compliance at ATRIO

Disclosures