About Us|Patients & Members|Health Plans|Hospitals & Clinics|Programs & Services|Doctors|Healthy Living|Careers

Provider Appeals and Grievances Form

Presbyterian encourages providers/practitioners to file claims correctly the first time or, if time allows, resubmit the claim through the Provider CARE Unit to resolve an issue.

A provider/practitioner is encouraged to contact his/her Provider Services Coordinator to help clarify any denials or other actions relevant to the claim and to help with a possible resubmission of a claim with modifications.

Provider Appeal and Grievance Form

Remember, a provider/practitioner has one year (12 months) from the date of services to file an appeal regarding a claim denial, or the denial will be upheld as past the filing limit for initiating an appeal. When filing an appeal, a provider/practitioner must be able to show documentation that timely follow-up was conducted into the matter. Timely follow-up includes proof of contact with the plan, such as patient ledgers or copies of written communications.

When filing an appeal, please remember to document the reasons for your reconsideration request, and attach all supporting documentation for review of the issue. If the issue involves a claims denial appeal, and you previously submitted the claim electronically, please include a copy of the claim in question for review of your appeal. If the appeal is related to a claims coding matter, it is helpful to include supporting medical records, such as office notes and operative reports, if applicable.

Please fill in the following form, and press the Send My Request button to send your inquiry to the Appeals and Grievance Department for review. We will reply as soon as we have researched the appeal/grievance for you.

All information is required for us to process your appeal/grievance.

Provider Name:
Provider Tax ID or AMISYS Number:
Provider Group Name (if applicable):
Provider Address:
Provider Phone Number: -
Submitted By:
Member Name:
Member Date of Birth: mm/dd/yyyy
Member ID:
SSN:
Date of Service: mm/dd/yyyy
Group ID:
Benefit Plan:

Product (please check all that apply):

Commercial/ASO:
Presbyterian Senior Care:
Salud:
PIC:

Reason for Appeal/Grievance

Supporting documentation must accompany the appeal/grievance. Failure to attach or submit supporting documentation may limit our ability to review this case further.

Attach Supporting Documentation:

For example, proof of timely filing, proof of contact with the Health Plan, patient ledgers, electronic copies of written documentation, denials from other insurance companies, electronic operative reports.

Note: Not all documentation may be transferable in an electronic form.

File 1:


File 2:


File 3: