Claim Denial Appeal Form

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Claim Denial Appeal Form Powered By Docstoc
					                                            Health Plan
Claim Denial                                Dental Plan A
Appeal Form                                 Employee Assistance Plan
                                            Wellness Plan
Please check the box for
appropriate Plan and option.

                                       PLEASE NOTE: Prior to filing an appeal with Marathon, you must first
                                       appeal any denial of benefits to the appropriate claims payer. Please
                                       attach a copy of the claims payer’s first level appeal response to this
                                       appeal form.

    Type of Appeal (select one):
     Non-Urgent Pre-Service Claim Appeal,                                  Refer to the Summary Plan Descriptions
                                                                            available on
     Post-Service Claim Appeal, or                                         for information regarding the various
     Urgent Pre-Service Claim Appeal.                                      types of appeals.

    I.     Please List Below the Information on the Individual (Spouse or Dependent if not the Member)
           for Whom the Claim was Denied:

    1. __________________________________________                       8. ______________________________________________
       (Last Name, First Name, Middle Initial)                             (Social Security Number) Please note: for the Purposes of
                                                                           the Health or Dental Plan, this should be the Social Security
                                                                           Number of the Plan Member named on the Health Plan ID
                                                                           card. For Wellness or EAP appeals, list the SSN of the

    2. __________________________________________                       9. ______________________________________________
       (Address)                                                           (Name of the Plan Member or Employee listed in 8 above)

    3. Phone Number (Daytime) _____________________

    4. Phone Number (Evening) _____________________                     10. Authorization of Plan Member or Employee to investigate
                                                                            claim and obtain information from the Providers listed in
                                                                            Section III below:

    5. _________________________________________                        ________________________________________________
     (Claims Payer who initially denied claim. For example,               Signature                              (Date)
    Anthem, Medco Health, UnitedHealthcare, etc.)

    6. _________________________________________                        11. Authorization of individual listed in #1 if that person is
    (Plan and Option Appeal is being filed for; example:                    over age 18 and is not the Plan Member or employee
    Traditional PPO, PPO Plus)                                              listed in #9 :

    7. _________________________________________
      (Date Claim Denied)

    II.    If the individual filing the appeal is a “personal representative” acting as a duly authorized
           representative, (such as a treating physician or other provider, the member if the member is
           acting on behalf of a dependent over age 18, or other individual) then the covered dependent
           (if over 18) must authorize the personal representative to act on their behalf.* If the covered
           dependent is under 18, either the member or other guardian must authorize the personal

    I/we have designated the following individual to
    represent me/us regarding this appeal: ______________________________________________________________
    (Please complete Authorization to release information on page 3)


    *This includes authorizing the employee member to act on the behalf of an over age 18 covered dependent or spouse if the employee
    member is filing an appeal on their behalf.
III.   Information on the Denied Claim (Also attach any supporting information/documents)

Date(s) of Service:                                   Service Providers:

Nature of Claim: ________________________________________________________________________________________



Why you are appealing the claim denial (for example, paid out-of network but you think it should be in network because…)

Additional Information Helpful for the Review: ______________________________________________________________




Send Claim To:           Plan Administrator – MOC Appeals
                         539 South Main Street
                         Room 3119
                         Findlay, OH 45840
         (To Authorize Release of Health Information to a Plan Representative
               for an Appeal When Appeal Requires Plan Health Information)

I, _________________________________ (print name) hereby authorize the use or disclosure of my health
information as described in this authorization.

       Marathon entity(ies) authorized to provide information to appropriate outside medical
        experts if required or to receive information from my providers (check the box of the
        appropriate plan or plans):
                  Health Plan
                  Dental Plans
                  Employee Assistance Plan
                  Wellness Plan

        This authorization includes the Plan itself, plan personnel, administrators, and outside entities
        retained to assist in the administration of the plan and the adjudication of claims.

   Specific person/organization (or class of persons) authorized to provide the information to the
    above entity: (include your treating physician, other health care providers, and any health care
    facility where you may have received treatment).

   Specific description of the information: (Example: Health information relevant to my appeal of a
    claims denial)
   Purpose of the request: (Example:             For the recipient of the health information to act as my
    representative in my claims denial)

   Right to Revoke: I understand that I have the right to revoke this authorization at any time by notifying
    the Privacy Officer of the Plan in writing at:
        Benefit Plan Privacy Officer
        Room 3119
        539 South Main Street
        Findlay, Ohio 45840
    I understand that the revocation is only effective after it is received and logged by the Plan. I
    understand that any use or disclosure made prior to the revocation under this authorization will not be
    affected by a revocation.
   I understand that after this information is disclosed, federal law might not protect it and the recipient
    might redisclose it.
   I understand that I am entitled to receive a copy.
   I understand that this authorization will expire at such time as a final decision is rendered on my appeal.

Signature                                                       Date:

(If an individual is signing using a Power of Attorney or other legal authority, please attach a copy of the Power of
Attorney or other relevant document)