Escalation Claim Form

There is a SUBMIT BUTTON at the BOTTOM which will turn BLUE when ALL REQUIRED FIELDS have been COMPLETED. This WILL NOT be accepted by MAIL/FAX it MUST be submitted electronically to be utilized: This form may only be used to submit requests for escalation of claims issues. Please follow the standard process for contacting the Provider Assistance Unit first. The call reference number will be required in order to escalate your claim inquiry. If you do not have a call reference number please contact 888-767-4670 and have your issue researched and documented by our PAU staff. If the issue is not resolved, you may then submit this form for escalation. A red asterisk (*) Indicates the field is mandatory.

Category*

One example is enough if this is part of a trend.

DO NOT INCLUDE PHI

Phone

PLEASE NOTE:

This is a final claims escalation form, please do not submit the same claim more than once. If you have additional questions, please contact the Provider Assistance Unit (PAU) 888 767 4670 between 7 am and 5 pm PST for a status.

DO NOT INCLUDE PHI

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