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Grievances and appeals online form

I want to file a grievance or appeal

1. Grievance details

Please provide details of the grievance or appeal in the fields below. All fields marked with an asterisk (*) are required.  


*Check the one that applies
For grievances, give the date of the issue or incident. For appeals, give the date on the Notice of Adverse Benefit Determination letter you received.
Describe your 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 information

Please provide the following information. All fields marked with an asterisk (*) are required.

Example: 12345
Example: 1234567890
*Are you filing this grievance or appeal on behalf of someone else?


Important note: Expedited decision


If you or your provider believes our standard time frame of 30 days to make a decision on your appeal will seriously jeopardize your life or health, you can ask for an expedited appeal.

Today's date

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