FEHB appeal form

Federal Employee Health Benefits plan appeal form

Personal information

1. First name *This question is required.

2. Last name *This question is required.

3. Contract ID number *This question is required. This question requires a valid number format.

4. Person completing form If other than member

5. Relationship to member

5. Member street address *This question is required.

6. City *This question is required.

7. State *This question is required.

8. ZIP *This question is required. This question requires a valid number format.

9. Home phone This question requires a valid number format.

10. Work phone This question requires a valid number format.

Appeal details

11. Was service authorized? By whom?

12. Under what section of your FEHB plan documents do you believe this service would be covered?

13. List the facts about this appeal. (dates, type of service, etc.)

14. What action are you asking Priority Health to take, and why?

15. Let us know if you will be sending in any additional information for the Grievance Committee to review.

ACKNOWLEDGMENT

By submitting this appeal, I understand that Priority Health will complete a thorough investigation of my appeal for review by the Appeal Committee. I understand that this may involve contacting appropriate providers to gather relevant medical records including photos, claims information relating to diagnosis, prognosis and treatment for physical and mental illness, mental health, substance abuse, communicable diseases and infections, and other conditions, ailments, sicknesses and diseases, including human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS).

*If a person other than the member is completing this form, we will need a HIPAA authorization from the member or a completed "Appointment of representative" form in addition to this form. Find them in the Member Handbook of this website, or search "member forms".