Appeals & Grievances Form - Providers | Presbyterian Health Plan, Inc.

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. Providers who are not contracted with Presbyterian Medicare Lines of Business have 60 calendar days from the remittance notification date to file an appeal 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 Submit 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.

Providers who are not contracted with Presbyterian Medicare Lines of Business must include a signed Waiver of Liability form with any appeal.

Provider Waiver of Liability Form

Please complete the form below.
* = indicates required fields

Provider's First Name*

Provider's Last Name*

Provider's Tax ID*

Provider's NPI*

Provider's Group Name (if applicable)

Provider's Address Line 1*

Address Line 2

City*

State*

ZIP*

Provider's Phone Number*

First Name of Person Submitting Form*

Last Name of Person Submitting Form*

Email of Person Submitting Form*

Member First Name*

Member Last Name*

Member ID* (if applicable, otherwise enter N/A)

Member Date of Birth*

Date of Service*

Group ID

Benefit Plan

Reason for Appeal/Grievance*

Add Supporting Documentation

Appeals may only be submitted for one member at a time (please do not include multiple members in one submission). An appeal letter should be included that clearly describes what you are appealing. Supporting documentation must accompany the appeal/grievance. Failure to attach or submit supporting documentation may limit our ability to review this case further. Examples of documentation include 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, etc.

Size of each file attached should not exceed 5MB (Total of 15MB combined for all three attachments)
Allowed file types: .doc, .docx, .rtf, .xls, .xlsx, .pdf

File 1

File 2

File 3