Free Case Review

Paxos Free Case Review

Thank you for your interest in working with Paxos Health. Please complete this form, and we will reach out once we have had a chance to review your answers and we are ready to proceed with your case. Please write 'NA' in the fields that do not apply to your case for any non-health insurance-related claims, or fill them out to the best of your ability.
Email*
Please use same email address as one used for contact form submission.
Email verification*
Please re-enter your email address.
Patient Name*

First NameLast Name
Who is filling out this form?*
If you are the patient, please write 'self'. If you are an authorized representative, please state your name and describe your relationship to patient.
Are you ready to move forward with our paid services, or would you prefer to begin with a free case review? Please note that the case review process may take up to 5 business days, which could delay our ability to start working on your case. If you're confident in proceeding, we recommend skipping the review to expedite the process.*

Skip case reviewStart with free case review
Which of our services are you most interested in at the moment? This is not a commitment, but we encourage you to read through the service descriptions on our website (paxosappeals.com/appeals-service).*

Tier 1 ($299)Tier 2 ($699)Tier 3 ($1,999)Not sure if interested in services
Who is your current medical insurer? *
What state are you located in?*
What state will your service performed in?*
If the service already occurred, what state was it performed in?
What treatment (surgery, medical service, etc.) are you having? *
What are the medical diagnoses related to your treatment?*
Has your treatment been scheduled or happened yet?*
Has your provider submitted a pre-authorization yet?*

YesNo
Date of procedure (or estimated date)*
Please provide the exact date when your medical procedure took place, or if it hasn't occurred yet, give your best estimate of the upcoming date.
Date of most recent pre-authorization or claim denial?
Please answer in MM/DD/YYYY format.
Name of your surgeon/treating provider*
How did you hear about Paxos?*
Examples include internet search, word-of-mouth, physician referral, lawyer referral, online community names, etc.
Please elaborate on your answer above if you can.
First and last name, office, firm, website etc.
Please upload your denial letter, or any other pertinent letters your insurer has sent you relating to this case

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If you're unable to upload a denial letter, please provide additional details explaining why.
Please upload your full insurance plan document (optional)

Please upload your plan document, also referred to as a benefit booklet or evidence of coverage (EOC) so our team can check plan language that may be relevant to your case. This is typically an 80+ page document found on your insurance portal. If you are unable to find this document at this time, you may skip this step for now and we will retrieve at a later date.
Cancelof
Please upload any appeals previously written and/or submitted (if applicable)

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Tell us more about your situation. Please provide as much detail as you'd like for our team to review in our analysis of your case.*

NOTE
We typically recommend waiting until your doctor has submitted a pre-authorization before proceeding with our service service. If you would still like to proceed with our service to get an appeal ready in advance, please note that edits may be required if your insurance provider changes between now and the time you submit it.

FINAL IMPORTANT NOTE

If you experienced a formal denial for your treatment, we HIGHLY recommend visiting this ProPublica site to create a Claim File Request to gather more information from your insurer about your case. Regardless of if you choose to work with Paxos Appeals, this will give you more information for your case.

Please do this now so that, if we do end up working together, you will hopefully have more information from your insurer.
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Paxos Free Case Review

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