Internal

Appeal Request Form
OR Fill out the form below:
LUCAS COUNTY EMPLOYEE HEALTH & DENTAL BENEFIT PLANS
ADMINISTERED BY NFP BENEFIT ALLIANCE
INTERNAL APPEAL REQUEST FORM
Name of Person Filing Appeal:
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*If you are an authorized representative you must complete the Appointment of Authorized Representative section.
  • Relationship to Covered Person:
  • Covered Person
  • Authorized Representative
Relationship to Covered Person:
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How would you like us to contact you?
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Contact information of authorized representative (if applicable)

Fax Number for Authorized Representative:
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Email Address for Authorized Representative:
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Mailing Address for Authorized Representative:
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Evening Phone for Authorized Rep:
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Daytime Phone for Authorized Representative:
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Covered Person / Applicant Information

Applicant Name:
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Applicant ID Number:
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Mailing Address for Applicant:
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Daytime Phone for Applicant:
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Email Address for Applicant:
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Evening Phone for Applicant:
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Fax Number for Applicant:
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Treating Physician / Health Care Provider Information

Treating Physician or Health Care Provider Name:
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Treating Physician or Health Care Provider Email:
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Treating Physician or Health Care Provider Contact:
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Treating Physician or Health Care Provider Mailing Address:
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Treating Physician or Health Care Provider Phone:
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Treating Physician or Health Care Provider Fax:
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Internal Appeal Specifications

Are you requesting an expedited appeal because your health, life or ability to regain maximum function may be in serious jeopardy while you wait up to 30 days for a decision on your appeal?
  • - select a option -
  • Yes
  • No
- select a option -
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Are you requesting an expedited appeal because your physician certifies that your pain can not be controlled while you wait up to 30 days for a decision on your appeal?
  • - select a option -
  • Yes
  • No
- select a option -
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Are you requesting a Concurrent Expedited Internal Appeal and Expedited External Review and your physician certifies that it is necessary? (Note: Request for External Review form is not required.)
  • - select a option -
  • Yes
  • No
- select a option -
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**If you answer YES to question 2 or 3 above, your physician must complete the Treating Physician Certification Form for Internal Appeal and/or External Review. You may also have your physician complete the certification form if you answer YES to question 1.
Briefly describe why you disagree with this decision (you may attach additional information, such as a physician’s letter, bills, medical records, or other documents to support your claim):
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Upload Supporting Documentation:
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Appointment of Authorized Representative (complete when someone else is representing you in this appeal)

You may represent yourself, or you may ask another person, including your treating health care provider, to act as your authorized representative. You may revoke this authorization at any time.
I hereby authorize said representative to pursue my appeal on my behalf:
Authorized Representative's Name:
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Date:
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Signature and Release of Medical Records

To appeal the denial of coverage, you must sign and date this Appeal Request Form and consent to the release of medical records.
I...
Full Name for Medical Release:
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...hereby request an appeal. I attest that the information provided on this form is true and accurate to the best of my knowledge. I authorize my treating physician, health care provider, and/or health plan issuer to release all relevant medical or treatment records to an independent review organization, the Ohio Department of Insurance, and/or my health plan issuer. I understand that the independent review organization, the Ohio Department of Insurance, and/or my health plan issuer will use this information to make a determination on my appeal and that the information will be kept confidential and not be released to anyone else. This release is valid for one year. I understand that I or my authorized representative is entitled to receive a copy of this authorization.
Date:
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Be certain to keep copies of this form, your Notice of Adverse Benefit Determination and all documents and correspondence related to this claim.

We have a team of expert professionals that possesses relevant experience in this domain. Our professionals work in close coordination with the clients and carefully analyze their specific requirements.

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