Appeal Form

If you think we have made a mistake in denying your medical service or you don’t agree with the decision, you can ask for an appeal. You must request an appeal within 60 calendar days from the date on the Notice of Action (NOA) sent to you. You may call Care1st to file an appeal verbally. If you file verbally, you will be asked to submit a written, signed appeal, excluding expedited appeals.

Member Information

Please fill out all of the following fields that contain important member information.

Appeal Information

This information becomes part of the permanent record.

  1. No
    If yes, you may file a Grievance with Care1st, or request an Independent Medical Review (IMR) or State Hearing.