Medical Appeals and Grievances
When should I use this form?
Use this form to submit:
• A question about a claim or your coverage.
• A formal review of a complaint regarding a claim, coverage determination
or service received.
View Appeal Rights Information
How do I submit a form?
• Wisconsin residents:
Print and complete the Wisconsin Member Service Request Form. 
• Residents of any other state:
Print and complete the Member Service Request Form.
What else may I need?
• To view an Explanation of Benefits (EOB), visit the CLAIMS section. Then, select Claim Summary and More Details for a claim.
• An appeal may be submitted by you or your authorized representative. Please use this Authorization of Release of Health Information Form.
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Common Questions
Most plans require that you submit your claim Appeal request for review to us in writing through the Member Service Request Form or a letter to the P.O. Box listed on the instruction page of the Member Service Request Form.
Once we receive your request for review, we will assign an appeals coordinator to conduct a full and fair review within the timeframe required by law.
The first request for an appeal should be sent to us no later than 180 days after you receive the EOB, unless your plan allows a longer time period for submitting an appeal. Please check your health benefits plan (e.g. Certificate of Coverage or Summary Plan Description) for more details.
For questions about your appeal rights, an adverse benefit determination, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). Your state consumer assistance program may also be able to help you.
An appeal is a timely request for a formal review of an adverse benefit decision, such as a claim denial or how we applied your deductible or coinsurance. An appeal may be submitted by you or your authorized representative.
We typically communicate our post-service benefit decisions on your Health Statement or Explanation of Benefits (EOB). For more information about our decision please review your Health Statement or EOB.