MANAGED CARE PROVIDER APPEAL REQUEST

Instructions

Use this form to request an MO HealthNet Division appeal review if a Managed Care health plan upheld a claim denial and your internal appeal with them was unsuccessful.

Important: This form is only for Managed Care claims. Do not use this form for Prior Authorization denials or Fee-For-Service claims. For assistance with those issues, contact Provider Communications via eMOMED or call (833) 222-7916.

Criteria for Submission:

You must meet all the following:

Your appeal process with the Managed Care health plan is completely exhausted
The plan upheld the denial
The issue was not resolved wholly in your favor

Required Documentation:

Your appeal cannot be processed without uploading:

Original Denial Letter from the Managed Care health plan
Initial Appeal you sent to the health plan
Appeal Determination Letter from the health plan upholding your denial
Supporting Medical/Billing Documentation (e.g., relevant medical chart notes, corrected claim forms, or proof of timely filing)

Multiple claims: If appealing multiple claims with the same denial reason (same or different participants), you can upload a single spreadsheet with all required data instead of filling out this form multiple times.

Submission:

Online submission is the fastest method. If you cannot use this online form, submit the Managed Care Provider Appeal Request and documentation via:

Email: MHD.ProviderAppeal@dss.mo.gov
Fax: (573) 526-3946
Mail: MO HealthNet Division, Education and Training, Attn: Appeals, PO Box 6500, Jefferson City MO 65109

Provider Information

Provider Name

Provider Phone Number

National Provider Number (NPI)

MO HealthNet Provider Number

Office Contact Name

Contact Email

Provider Street Address

City

State

Zip Code

Participant Information

First Name

Last Name

Middle Initial

Date of Birth

DCN/MO HealthNet ID Number

MC Health Plan

Healthy Blue

Home State Health

Show Me Healthy Kids

United HealthCare

Claim Information

Denied Service or Claim ICN

Date Denied

Denied Date(s) of Service

Billed Amount

Only allows numbers

Denial Reason

Appeal Information

Date of Managed Care Health Plan Appeal Denial Determination

Reason for the Appeal

Supporting documents must be attached (denial letter, initial appeal to Managed Care health plan, appeal determination letter, and supporting medical/billing documentation).

CAPTCHA

The MO HealthNet Division (MHD) will email you when your appeal is under review, or if we need more information. You will receive an email with the final decision within 90 calendar days of MHD’s initial review.

Contact MHD.ProviderAppeal@dss.mo.gov for any questions.

The Form ID for this submission is {formuniqueid}.

Form ID