Provider services

Submit an appeal.

For providers responding to a ClaimReturn case. Documentation submitted through this form is encrypted in transit and reviewed by authorized personnel only.

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HIPAA-compliant submission
Encrypted in transit · Access-controlled storage · Reviewed by authorized personnel only
Explain why you disagree with the determination. Appeals without a stated reason won't be reviewed.
0 / 2000 characters
Please include:
  • Claim form: UB-04 (CMS-1450) or CMS-1500
  • Payment documentation: the payer's remittance advice or Explanation of Payment (EOP)
  • Supporting documents (optional): anything else relevant to your appeal
PDF files only. Maximum 8MB per file, 10 files and 24MB total.

This appeals form is protected by industry-standard TLS/SSL encryption, ensuring all information and documents you submit are encrypted in transit. Uploaded files are stored in a restricted, access-controlled environment and are only viewed by authorized ClaimReturn personnel for the purpose of processing your appeal.

ClaimReturn does not sell, share, or disclose your information to third parties except as required to process your case. No data submitted through this form is accessible publicly.