TRICARE West - Health Net Appeals Form

Claim or Authorization Denial Information

= Required Field

If you have more than 5 claims, enter additional claim numbers below in the “Issue in Dispute” section.

If you have more than 2 authorization/ reference, enter additional numbers below in the “Issue in Dispute” section.

Appeals must be submitted within 90 days from the date of denial. Please be sure to include the reason for the delayed appeal if this date is more than 90 days ago.


Preview

Submitter Information

Relationship to Patient / Beneficiary

Describe your relationship:

Group/Facility Name:

Individual Provider Name:

Tax ID Number (TIN):

Agency Name:

Name:

Date of Birth:

Street Address:

City:

State:

Zip Code:

Extension:

Daytime Fax number:

Email Address:

Sponsor Information

Name:

SSN:

Patient / Beneficiary Information

Name:

Date of Birth:

Street Address:

City:

State:

Zip Code:

Rendering Provider / Facility Information

Group/Facility Name:

Individual Provider Name:

Street Address:

City:

State:

ZIP Code:

Daytime Phone Number:

Extension:

Fax Number:

Tax ID Number (TIN):