New Appeal
Start Date
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Minutes
Reference Number
*
Care Manager
Please Select
Annette Watkins
Cheryl Butler
Deborah Fotta
James Miller
Lee Ann Patterson
Linda Evans
Marcy Riley
Marianne Cole
Maureen Quinn
Sylvia Schmitt
Wendy Pudlak
Susan Cooney
Anne Jones
Stacy Yefko
Jaime Reed
Samantha Betty
Melissa Taylor
Andrea Marquez-Alvaro
Camille Huzzard
Terrie Morrow
Dorothy Holmes
Shontae Bell
Vendor
Please Select
CareCore
Healthways
NaviHealth
NIA
None
First Name
Last Name
UMI
*
Appeal Requestor
*
Please Select
Provider
Member
AOR Representative
AOR on File?
Yes
No
Line of Business
Please Select
Blue Rx
CommunityBlue
FreedomBlue (PA)
FreedomBlue (WV)
SecurityBlue
Service Type
Please Select
Chiropractor
CORF
Dental
DME
Home Health
Inpatient
Inpatient Rehab
OT
Outpatient
Pharmacy
PT
Speech
SNF
Other
Source of Initial Denial
Please Select
Organizational Determination
CareCore
Healthways
Member Services
NaviHealth
NIA
Pharmacy
Type
*
Part B
Part C
Part D
Standard
Standard 60
Org Determination
Provider Appeal
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