Fillable Kentucky Medicaid Mco Member Appeal Request Form printable pdf download

Kentucky Medicaid Mco Member Appeal Request Form

Download a blank fillable Kentucky Medicaid Mco Member Appeal Request Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Kentucky Medicaid Mco Member Appeal Request Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Member Appeal –MCO 012016

Kentucky Medicaid MCO

Member Appeal Request

MCO

Phone

Fax

 Anthem BCBS Medicaid

1-855-661-2027 Ext. 26740

1-855-443-7820

Check the box of

the plan in which

 Coventry Cares/Aetna Better Health

1-855-300-5528

1-855-454-5585

the member is

 Humana – CareSource

1-877-892-7487

1-855-262-9794

enrolled

 Passport Health Plan

1-800-578-0636

502-585-8461

 WellCare of Kentucky

1-877-389-9457

1-866-201-1657

Please complete all appropriate fields

If you need assistance with this form, call your MCO at the number listed above

All Appeals must be filed within 30 days from the date of MCO action

Date _______________________

Person filing request ________________________________ Email ______________________________ Phone _______________

 I am a Medicaid member  I am filing request on behalf of a Medicaid member

If filing on behalf of member, state relationship to member ________________________________________________

Who is the Appeal for?

Member’s name ____________________________________________________________________________________

Member’s Social Security Number_____________________ Member’s DOB ____________________________________

Member’s address ______________________________________________________________ County _____________

Why are you requesting an appeal?

Procedure or Service you are requesting_________________________________________________________________

Doctor or Provider of service ______________________________________________________ Phone ______________

Doctor or Provider address ___________________________________________________________________________

Reason for procedure/service _________________________________________________________________________

Please give as much detail as possible about this request:

Attach a copy of the denial letter along with any other correspondence concerning this request.

 By signing this document, I authorize the person submitting this form to do so on my behalf

Signature of Member ____________________________________________________________ Date _______________

Signature of person filing request __________________________________________________ Date _______________

Members have the right to request a continuation of benefits while the Appeal is being processed

This form complies with the Appeal process as outlined in KAR 17:010

Kentucky Medicaid Mco Member Appeal Request Form

Related Articles

Related forms

Related Categories