Appeals Form Submit - ClaimReturn

ClaimReturn - Medical Cost Containment Services

Appeals Form

If you wish to file an appeal of a ClaimReturn finding, please use this form to submit any pertinent information. We will respond to you as soon as your appeal has been evaluated by our team.

If for some reason you are not able to work with this form, please email your appeal with the same information as below to appeals@claimreturnllc.com.

NOTE: Fields marked by * are required, you will not be able to submit the form without all of the required information.

APPEAL INFORMATION

Name *

Your Position

Healthcare Provider or Facility Name *

Provide Your Contact Information

Address *

City *

State *

Zip code *

Phone *

Fax *

Email *

Appeal Details

Claim Number

ClaimReturn Case Number *

Your Patient Account Number *

Include a written summary of your dispute and the documentation to support your dispute.
You can upload any files you wish to support your appeal. Uploads are limited to Word, Excel or PDF documents.
You can select and submit multiple files if necessary.

Summary of your dispute *

Supporting Documentation

Provider Password (as provided in EOB or Letter): *

Submit