Request For External Appeal Form - Minnesota Department Of Health

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STATE OF MINNESOTA
DEPARTMENT OF HEALTH
Request for External Appeal
Enrollee Information
Enrollee Name: ___________________________________________________________________________________________
Dependent Name (if appeal is on behalf of a person other than the health plan policy holder): ______________________________
________________________________________________________________________________________________________
1
Enrollee Address
: _________________________________________________________________________________________
Street Address
________________________________________________________________________________________________________
City
State
Zip Code
Enrollee Phone: Day: _______________________________________
Other: _______________________________________
Enrollee Insurance ID#: _______________________________
YOU HAVE THE RIGHT TO PICK A PERSON TO REPESENT YOU IN YOUR APPEAL. IF YOU CHOOSE
TO BE REPRESENTED BY SOMEONE, YOU MUST COMPLETE AND SIGN THIS SECTION TO APPOINT
2
A REPRESENTATIVE
:
Enrollee Representative Information (Optional)
Representative Name: ______________________________________________________________________________________
Relationship to Enrollee: ____________________________________________________________________________________
Representative Address: ____________________________________________________________________________________
Representative Phone:
_______________________________
I am the “enrollee” identified above and I authorize the person (identified above) to represent me in my external appeal.
Enrollee Signature: _________________________________________________________________________________________
Health Plan or Utilization Review Company Information
(Enter the name of the company that
denied your claim.)
Health Plan Name: _________________________________________________________________________________________
Health Plan Address: _______________________________________________________________________________________
________________________________________________________________________________________
Denied Service/Summary of Appeal
(Enter a brief description of the claim, request, treatment or service
you believe was denied and why you are appealing this denial. Attach a copy of the denial issued by the insurer.)
(Note: Your health plan will be asked to send the reviewing entity the complete
Additional Information
record of your appeal, including any information you have already given them. However, you can include with
this form any letters, documents or description that you want to send us.)
CHECK:
___ I am
___ I am not, including additional information.
1
Write the address we should use to send you mail about your case.
2
An enrollee signed authorization is not required if the enrollee is not competent and is represented in compliance with Minnesota Law.
09/29/14

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