MEMBER APPEAL FORM

MEMBER APPEAL FORM
NetCare Health will accept your request for an appeal when the request is submitted within 180 days of receipt of a denial notice. If more than 180 days have passed since you were notified, and you still have a question, please call Customer Service using the number on the back of your member ID card.

An appeal is a request to change a previous adverse decision made by NetCare Health. You or your representative (including a physician on your behalf) may appeal the adverse decision related to your coverage.

Complete and mail this form and/or appeal letter along with any supporting documentation to the address identified below.
REQUESTS FOR AN APPEAL SHOULD INCLUDE:
1. If you submit a letter without a copy of the Member Appeal form, please specify in your letter this is a “Member Appeal”. Please include all the information that is requested on this form.

2. Any documentation supporting your appeal. For adverse decisions based upon lack of medical necessity, additional documentation may include a statement from your healthcare professional or facility describing the service or treatment and any applicable medical records.
Subscriber's Name

First NameMILast Name
Subscriber ID Number
Subscriber's Mailing Address
Phone Number
Member's Name (Last)
(First)
(MI)
Appeal is being filed by:

Subscriber Spouse Child OtherAppeal is being filed by:Health Care Professional or Facility NameDate of ServiceOther
Date of Birth

MonthDayYear
Date
Health Care Professional or Facility Name
Date of Service

MonthDayYear
Date
Claim Number /Authorization Number
Note: If your selection is spouse, child (18 years of age or older) or other, please complete and include the attached Authorized Representative Form with your request.
Name of person filling out the form
Today's Date

MonthDayYear
Date
Phone Number

Area CodePhone Number
Signature

Clear
Mail this completed form or Appeal Letter along with all supporting documentation to: NetCare Life and Health Insurance 424 West O’Brien Drive, Suite 200 Hagatna, Guam 96910
Please Explain the Reason Why You're Appealing (Use additional pages if necessary.)
Should be Empty:

MEMBER APPEAL FORM

REQUESTS FOR AN APPEAL SHOULD INCLUDE: