If you disagree with the decision for a request for coverage or payment for a service, you have the right to ask us for a reconsideration/redetermination (appeal) of our decision. You have 60 days from the date of our notice of denial to ask us for an appeal. For assistance with this form or questions regarding your appeal, please contact our Customer Service department at 1-877-672 8620 (TTY 711), daily from 8 a.m. to 8 p.m. PST.
Who May Make a Request: In addition to you, your physician/prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. To appoint another person to act as your representative, contact Customer Service and request an “Appointment of Representative” form.