MEMBER GRIEVANCE AND APPEAL FORM
HealthLink members have the right to document a grievance or file an appeal by filling out a simple form.
If you are enrolled in a health plan that uses the HealthLink network, you may use the Member Grievance Form to file a medical grievance such as the quality of service or care received, or file a medical appeal to an adverse benefit determination (i.e. claim denial). To make sure our office has the information necessary to thoroughly review the issue, please complete all fields and include specific details (physician or facility name, date of service, billed amounts, reason for submitting the form, etc.). You may mail or fax the completed form to the specified PO Box and fax number listed on the form.
If you enrolled in a health plan that uses a HealthLink network, please contact your plan benefits administrator, identified on your ID card, for questions regarding adverse benefit determinations.