[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288920-105":53,"doc-detail-288920-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","anthem-non-par-appeal-form-provider-claim-appeal-request-form","Anthem Non-Par Appeal Form - PROVIDER CLAIM APPEAL REQUEST FORM","","Provider Claim Appeal Request Form for submitting an appeal when a claims inquiry outcome is disputed or additional information is available for re-evaluation by Carelon Post Acute Solutions. The form requires claim numbers and supporting documentation and must be submitted within 90 days of the denial date listed on the EOP. Submission is not a guarantee of payment changes, and an acknowledgement letter is sent within 10 calendar days. Includes appeal reason categories, supplemental documentation checklists, secure encrypted email submission details, and a waiver of liability section with signing.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/anthem-non-par-appeal-form-provider-claim-appeal-request-form/288920/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/anthem-non-par-appeal-form-provider-claim-appeal-request-form/288920.png","ImageObject",442,249,{"name":88,"@type":89},"wps_ap_test_251126_0180","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"When must the provider submit the appeal after a denial?","Question",{"text":109,"@type":110},"The appeal request must be received within 90 days of the denial date listed on the EOP.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What information and documentation must be included with the appeal request?",{"text":114,"@type":110},"The appeal must include the claim number(s) and supporting documentation, such as a complete copy of the medical records and the claim form.",{"name":116,"@type":107,"acceptedAnswer":117},"Does submitting an appeal guarantee a change in payment disposition?",{"text":118,"@type":110},"No. Review of a claim does not guarantee a change in payment disposition.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},288920,1790094466,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},8796095027276,"https://avatar.qwps.com/avatar/d3BzX2FwX3Rlc3RfMjUxMTI2XzAxODA=","PROVIDER CLAIM APPEAL REQUEST FORM  \nThis form should be used if you disagree with the outcome of your claims inquiry or have additional information which may warrant Carelon Post Acute Solutions to re-evaluate its original decision.  \n• An appeal request must include claim numbers and supporting documentation (e.g. complete copy of the medical records and claim form) .  \n• The appeal request must be received within 90 days of the date of denial listed on the EOP.  \n• Review of a claim does not guarantee a change in payment disposition.  \n• An acknowledgement letter will be sent to you within ten (10) calendar days upon receipt of the Appeal Form.  \n\n| Provider Information:\u003Cbr>Provider Name:  \u003Cbr>Provider NPI \\#:  |\n| --- |\n| Claim Information:\u003Cbr>Member Name:   Claim Number(s):  \u003Cbr>Member Group & ID \\#:   Date(s) of Service:   |\n| Reason for Appeal:\u003Cbr>􀂅 Timely Filing – Claims with DOS submitted beyond the allowed days as outlined within providers contractual agreement\u003Cbr>􀂅 Pricing – Incorrect payment or application of benefits\u003Cbr>􀂅 Eligibility – Payment issued for ineligible charges, claim processed as incorrect member, incorrect order of payment or other issues related to member eligibility\u003Cbr>􀂅 Medical Policy – Appeal a denial for failure to obtain prior authorization (Supporting documentation required) .\u003Cbr>􀂅 Other – Provide a detailed description\u003Cbr>Description of Claim Appeal:\u003Cbr>Supplemental Documentation Attached:\u003Cbr>􀂅 Remittance Advice 􀂅 Refund 􀂅 Medical Records 􀂅 Other (e.g. Timely filing Documentation) |\n| Contact Information:\u003Cbr>Requester:  Phone \\#:   Date:  |\n\nPlease submit completed form and attachments via secure and encrypted email to:  \n[claimappeals@mynexuscare.com](claimappeals@mynexuscare.com)  \nWAIVER OF LIABILITY STATEMENT  \nClaim \\#:  \n\n| Enrollee’s Name: | Member ID: |\n| --- | --- |\n| Provider: | Dates of Service: |\n| Health Plan: |  |\n\nI hereby waive any right to collect payment from the above-mentioned enrollee for the aforementioned services for which payment has been denied by the above-referenced health plan. I understand that the  \nsigning of this waiver does not negate my right to request further appeal under 42 CFR 422.600.  \n\n| Signature: | Date: |\n| --- | --- |","cbCaigNRZyfiVxYU","https://ap.wps.com/l/cbCaigNRZyfiVxYU","pdf",174902,"English","# Provider Claim Appeal Request Form\n## Submission requirements\n## Claim and appeal details\n## Supplemental documentation\n## Contact and waiver of liability","[{\"question\":\"When must the provider submit the appeal after a denial?\",\"answer\":\"The appeal request must be received within 90 days of the denial date listed on the EOP.\"},{\"question\":\"What information and documentation must be included with the appeal request?\",\"answer\":\"The appeal must include the claim number(s) and supporting documentation, such as a complete copy of the medical records and the claim form.\"},{\"question\":\"Does submitting an appeal guarantee a change in payment disposition?\",\"answer\":\"No. Review of a claim does not guarantee a change in payment disposition.\"}]","Anthem Non-Par Appeal Form - PROVIDER CLAIM APPEAL REQUEST FORM | PDF",1789634219]