Marketplace Appeal Number. Appeal Type: (Check one) Appeal of Claim Denial Check here if additional information is included. Please do not staple additional information to this form. Appeal of Medical Necessity Please be aware that written member consent is required if you are filing a pre-service appeal on behalf of a member. Return this form to: CareSource Marketplace Eligibility Appeal Rights If consumers believe there was a mistake or disagree with certain eligibility determinations made by a Marketplace, they have a right to request an appeal This presentation is about appealing to the U.S. Department of Health & Human Services (HHS) Appeals Entity about a Marketplace eligibility determination After the appeal is submitted, the Marketplace Appeals Center (1-855- 231 - 1751 or TTY users 1 - 855 - 739 - 2231) can answer appellants’ questions about their appeal.*
An appeal is a legal action you can take when you receive a final eligibility decision from the Marketplace and you do not agree with it. You generally have 90 days from when the decision is made to appeal it. You can mail or fax appeals to the Marketplace. Page 1 of 2 . 7/2016 . Form Approved . Employer Appeal Request Form . OMB No. 0938-1213. Appeal Request Form – Employer . Use this form to appeal a Marketplace determination that an employee was eligible for advance payments of the
An appeal is a legal action you can take when you receive a final eligibility decision from the Marketplace and you do not agree with it. You generally have 90 days from when the decision is made to appeal it. You can mail or fax appeals to the Marketplace.
You can either fax or mail your appeal. W e spoke to someone at the appeal center who indicated that faxed appeals will be handled more quickly, although both fax and mail are acceptable. The fax number is 1.877.369.0129 or you can mail it to: Health Insurance Marketplace Department of Health and Human Services 465 Industrial Blvd London, KY. After the appeal is submitted, the Marketplace Appeals Center (1-855- 231 - 1751 or TTY users 1 - 855 - 739 - 2231) can answer appellants’ questions about their appeal.* That notice will also describe your appeal rights. Learn more about when the Marketplace needs documents to confirm information from your application. Decisions you can’t appeal through the Marketplace. The Marketplace Appeals Center can’t review these types of issues: You disagree with the date the Marketplace ended your coverage. Fax Number: 937-531-2398 Mailing Address: CareSource, Attn: Member Appeals, P.O. Box 1947, Dayton, OH 45401-1947 If you need help with this form, you may call the Member Services departments for your state, Monday through Friday, 7:00 a.m. to 7:00 pm: Georgia Marketplace Members: 1-833-230-2030 Indiana Marketplace Members: 1-877-806-9284
