Form Wcpc-Imc-066 - Provider Appeal Request Form
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2Provider Appeal Request Form
Harmony Health Plan
HealthEase
Request Date: _____________
Healthy Kids
Has the service been provided yet?
Yes
No
Staywell
Expedited Request?
Yes
No
WellCare Choice
(See reverse side for definition of Expedited Request)
WellCare Commercial
Provider/Appellant Information
Patient Information
Name: ____________________________________
Name: __________________________________
Address: __________________________________
ID Number: _____________________
City: _____________________________________
Date of Birth: ________________________
Telephone: ________________________________
Service Provided Information
Fax: _____________________________________
Date(s) of Service: __________________
Contact Person: ____________________________
Place of Service: _________________________
√ Reason Given for Denial (from EOB or denial letter)
__ Medical Necessity
__ Inclusive
__ Lack of Information
__ Exclusive
__ Not Prior Authorized
__ Incidental
__ Benefits Exhausted
__ Medicare Payment In Full
__ Out of Network
__ Claim Not Billed as Authorized
__ Not a Covered Benefit
__ Exceeds Authorization
__ Untimely Filing
__ Other: _________________________
__ Invalid Code
Reason for Request:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_______________________________________________________________________________________________
Unless your contract allows otherwise, Harmony will pay the Medicare or Medicaid allowable, depending on member’s plan, for the
service performed if we overturn our previous decision. By signing this form, you agree to these terms and will not bill the member,
except for applicable co-pays.
Signature: _______________________________________
Date: _______________________
This form is to be used when you want to appeal a claim or authorization denial. Fill out the form completely and keep a copy for your
records. Send this form with all pertinent medical documentation to support the request to Harmony Health Plan, Attn: Appeals
Department, P.O. Box 31368 Tampa, FL 33631-3368. You may also fax the request if fewer than 10 pages to (866) 201-0657. Your
appeal will be processed once all necessary documentation is received and you will be notified of the outcome.
See other side for additional information.
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Parent category: Medical