File an Appeal (Level 2 Claim Appeals)

This is for providers and members to submit Level 2 Claim Appeals after a Level 1 Claim Appeal has been completed.

*Please note, there are required documents.

Is a Provider or other person submitting this Appeal?

Is a HIPAA Release of Information/Authorization attached?

PEBP Member Name

First and Last name

PEBP ID #*

Located on your PEBP Insurance Card with the black and white PEBP logo in the upper-left hand corner. Any other number will result in additional delays.

Patient Relationship to Primary Insured*

Select

Claim Number*

If this claim is before 07/01/2022, it will start with "NEV"

Health Plan

Select

REQUIRED Appeal Attachments*

You will be required to submit the following documents for consideration:

> Explanation of Benefits: From UMR

> Level 1 Claim Appeal: Your initial request for appeal sent to UMR.

> Level 1 Claim Appeal Determination: UMR response to your appeal.

> Level 2 Claim Appeal: A narrative for the appeal to PEBP.

> Any other documentation supporting the Level 2 Claim Appeal.

Failure to submit these documents may result in delayed processing or a rejected appeal.

Drag and drop files here or

Is the Explanation of Benefits attached?*

This is from UMR.

Is the Level 1 Claim Appeal attached?*

This is what was submitted to UMR.

Is the Level 1 Claim Appeal Response attached?*

This is from UMR.

Contact E-mail Address

Please provide your preferred contact e-mail address.

Additonal Comments

Send me a copy of my responses

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