[Grievances/ Complaints] and appeals online form

I want to file a [grievance/complaint] or appeal

1. [Grievance/Complaint] details

Tell us about the [grievance/complaint] or appeal in the fields below. You’ll want to fill in all fields with an asterisk (*).

*Check one:

I’m filing a [grievance/complaint].

I’m filing an appeal.

*Date For [grievances/complaints], give the date of the issue or event. For appeals, give the date on the Notice of Adverse Benefit Determination letter you received.

*Description

Tell us about the [complaint/grievance] or appeal. You can send us medical records or other info to support your appeal. Use one of the methods at the bottom of this form.

2. Member info

Share your info in the fields below. You’ll want to fill in all fields with an asterisk (*).

*Name

*Date of birth

*Address 1

Address 2

*City

*State

*Zip Code Example: 12345

*Phone Number Example: 1234567890

*member plan id number

*Are you filing this [grievance/complaint] or appeal for someone else?

Yes, I’m a representative.

No, I’m the member.

Representatives are family members, friends, caregivers or providers. This is someone the member approved in writing to act for them. Or others legally able to act for the member. It can be the member’s legal guardian. Or someone who holds power of attorney. You’ll need to send us this proof of representation if you haven’t already. You can send it using one of the methods at the bottom of this form.

3. Representative info

Share the representative’s info in the fields below. You’ll want to fill in all fields with an asterisk (*).

*Name

*Relationship Your relationship to member

*Date of birth

*Address 1

Address 2

*City

*State

*Zip Code Example: 12345

*Phone Number Example: 1234567890

Expedited appeals

You can ask for an expedited appeal if you or your provider believes our standard time frame of 30 days to make an appeal decision will risk your life or health.

Check this box if you believe you need a decision within 72 hours. If you have a supporting statement from your provider, you can send it using one of the methods at the bottom of this form.

*Sign

*Date Today's date

*Who are you?

Contact us

You can send us more info by:

Fax: [State-specific Member Services fax/Grievance and appeals fax number]
Email: [State-specific grievance and appeals email]
Mail: ${plan_name_circle_R} of ${state_name}

Attn: [Grievance and Appeals
PO Box 81139
5801 Postal Road
Cleveland, OH 44181]

What's covered?

Apply or renew

For members

Health and wellness

[Grievances/ Complaints] and appeals online form

I want to file a [grievance/complaint] or appeal

Expedited appeals

Contact us