Appeal/review Form - Wellmark, South Dakota

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APPEAL/REVIEW FORM
PLEASE PRINT OR TYPE ALL INFORMATION
This form is to be completed by you, as a covered member, or your authorized representative, if you have designated one, if you disagree with a
benefit determination or request a review of a claim for benefits.
Member Information
Member Name:____________________________________
Identification Number (from your ID card):___________________________
If your appeal is related to an application submitted to Wellmark, please include the tracking and/or offer number from the letter you received
from Wellmark: _________________________________________________________________________________________________
Patient Name:_____________________________________
Telephone Number: ____________________________________________
Mailing Address:________________________________________________________________________________________________
Requester’s Information
If you are requesting an appeal on behalf of the member, a Personal Representative Appointment and Authorized to Release Protected Health
Information Form must be completed and either be submitted with this form or on file with Wellmark. A member may appoint only one
authorized representative at a time.
This appeal is being requested by (Full Name): _________________________________________________________________________
Mailing Address: _______________________________________________________________________________________________
Telephone Number: _____________________________________________________________________________________________
Relationship to Member: _________________________________________________________________________________________
Claim Information (found on the front of the Explanation of Health Care Benefits or letter of denial or reduction)
Has the service in question already been provided?
 Yes
 No
Date of Service(s): ______/______/______ ; ______/______/______
Date of Denial: ______/______/______
Provider Name: __________________________________________
Provider Name: ________________________________________
Claim Number(s): ________________________________________
Date of declination/offer letter: _____________________________
Please provide an explanation of your appeal and attach any and all additional documentation that may assist us in our review. Include what
action you would like to see taken and use separate sheets if additional space is necessary. Your request for a grievance must be filed within 180
days of the date on the Explanation of Health Care Benefits or letter of denial or reduction. You will receive a written response to your request
within the time required by law.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Are there documents attached? (Please retain a copy for yourself)  Yes
 No
Signature:______________________________________________________________________
Date: ______/______/______
Mail to:
Wellmark Blue Cross and Blue Shield
Member Appeals, Station 351
PO Box 5023
Sioux Falls, SD 57117-5023
C-3347 3/11

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