This browser is not supported. Please use Edge, Chrome, Mozilla Firefox or Safari to submit this form.

 

Estimated time to complete

5 - 10 minutes

 

What you’ll need

  • Member information (Member ID and Medicare ID)
  • Reason for your appeal or grievance
  • Supporting documentation (medical records, letters, bill or receipt, or any other information)

 

 

This form is for filing an appeal or grievance about 

  • Filing an appeal
  • Filing a grievance

 

Learn more about

 

 

Submit this for Medicare Plans

  • Medicare Part D
  • Medicare Advantage
  • Medicare Advantage Prescription Drug
  • Dual Special Needs Plans

 

 

Legal Representative 

If you aren’t the subscriber and are submitting this form on their behalf, you will need to complete, sign, and upload a copy of the Designation of Authorized Representative form. Click for more legal representative information.

Email verification

Fields marked with an asterisk * are required

Let's verify your contact information

“Please enter your email address and select Send code. We’ll send a code to the email address you entered to verify the address is valid. If you don’t get the email, make sure the address you entered is correct or check your spam folder.”

Re-enter your email address to verify that it is correct. 

Code sent. Please check your email for your code and enter it below.

Member information

Fields marked with an asterisk * are required

Please complete the subscriber's information

Enter the Member ID number located on the member's ID card. Do not include numbers after the dash, spaces, or special characters (use 123456789 instead of 123456789-00). Here is an example.

Member ID card image

Enter the 11-digit Medicare number found on the red, white, and blue Medicare card.

Medicare card image

Submitter information

Fields marked with an asterisk * are required

Please print, complete and upload an Appointment of Representative form (PDF), or upload one of the following proof of legal representation documents you may already have: 

  • Appointment of Representative form
  • Power of Attorney
  • Advance Directive
  • Conservatorship documents 
  • Other legal representative contracts

Accepted file types: DOC, DOCX, JPG, JPEG, MSG, PDF, PNG, TIF, TIFF, TXT

Maximum file size:  25 MB

Request type

Fields marked with an asterisk * are required

If services are related to medical, dental, vision or Optum behavioral health issues, select Medical.

If the service, receipt, claim, invoice or superbill is related to medical, dental, vision or Optum behavioral health issues, select Medical.

Error: You previously told us you already received your prescription. Please select Processed Claim Appeal or Grievance to continue submitting your request. 

Please call the customer service number on the back of the member's ID card for help.

Provider information

Fields marked with an asterisk * are required

Select Individual provider if your receipt, claim, invoice or superbill has the name of the physician who provided services (examples: Jane Smith, NP; John Jones, MD; Sally Smith, PA).

Select Provider group if your receipt, claim, invoice or superbill doesn’t have the name of the physician who provided the services, but there is a provider group or organization listed (examples: LabCorp, Primary Medical Group (PMG), Rite-Aid, CareMount Medical).

Enter the provider's last name

Enter the provider's first name

Please list the provider who prescribed the medication / drug

Please list the provider who prescribed the medication / drug if known

Submission details 

Fields marked with an asterisk * are required

Click here to view a sample of the medical coverage denial letter.

Click here to view a sample of the Medicare prescription drug denial letter.

Please enter the authorization information

Enter the authorization/pre-service reference number.  You can find  your authorization/pre-service reference ID number at the top right corner of your pre-service denial letter. If your authorization/pre-service reference number has a dash, for example PA-1234567, enter the dash in your submission.

This authorization number entered wasn't found in our system. Please select from the following list of denied authorizations we found on file.

We were unable to find a matching authorization in our system. Please continue on with your submission.

Please enter the date(s) of service for the processed claim you are filing this request for

End Date should be greater than or equal to Start Date

Complete the submission 

Fields marked with an asterisk * are required

Providing supporting documents will aid in the appeal review. Attach a clear and legible copy of your health statement, Explanation of Benefits, medical records, pre-service denial letter (if available), or any other documentation that may help us understand your request. 

If you get an error message during your upload, please make sure your attachment is one of the following file types:

Accepted file types: DOC, DOCX, JPG, JPEG, MSG, PDF, PNG, TIF, TIFF, TXT

Maximum file size:  25 MB

Maximum number of uploads (20) has been reached.

Invalid files attached, please remove.

Duplicate files attached, please remove.

Review and submit

Review the details below and make any changes before submitting your request

Agree and sign

From time to time, United Healthcare Services, Inc., or their affiliates, subsidiaries, agents, contractors, or vendors (we or us) may be required by law to provide to you certain written notices or disclosures. Please read the information below carefully and agree to this Electronic Record and Signature Disclosure (ERSD). Please confirm your agreement by selecting the check-box next to ‘I agree to use electronic records and signatures’ before signing this document'.

 Getting paper copies

At any time, you may request a paper copy of any record provided or made available electronically to you by us. You will have the ability to download and print documents we send to you during and immediately after this signing session.

 Acknowledging your access and consent to receive and sign documents electronically

By selecting the check-box next to ‘I agree to use electronic records and signatures’, you confirm that:

  • You intend to sign the document electronically.
  • You can access and read this Electronic Record and Signature Disclosure.
  • You can receive electronic communications regarding this Electronic Record.
  • You acknowledge that emails containing your protected health information will be sent unencrypted and there is a risk of interception or disclosure of the contents of the emails. 
  • You can print on paper this Electronic Record and Signature Disclosure, or save or send this Electronic Record and Disclosure to a location where you can print it, for future reference and access.

 By signing this form in the ‘Submitter signature’, you understand that;

  • The information entered in this Electronic Record is accurate and true.
  • Your (or your authorized representatives) electronic signature is the legal equivalent of your manual signature.
  • Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete, or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.

Note: You need to scroll through the information above before you can check the box.