Appeal Form

Appeal, Complaint, or Grievance Form

Please complete the form below to submit an appeal, complaint, or grievance to DDCO for determination. Please note as indicated on all Explanations of Benefits and Explanations of Payments that appeals, complaints, or grievances must be submitted within 60 days of the processing of the claim for Medicare Advantage enrollees per CMS regulations, or within 180 days of the date of processing for all others. Appeals, complaints, or grievances received after these deadlines will be dismissed. Whether processed or dismissed you will receive notice via USPS within 60 days of receipt. For questions, contact appeals@ddpco.com

* Required fields

Subscriber/Patient Information

Subscriber First Name *

Subscriber First Name is mandatory

Patient Full Name (if other than Subscriber)

Patient Full Name (if other than Subscriber) is mandatory

Subscriber ID number or SSN (without dashes) *

Subscriber ID number or SSN (without dashes) is mandatory

Subscriber Last Name *

Subscriber Last Name is mandatory

Patient Date of Birth *

Patient Date of Birth is mandatory

Name of Employer (if applicable)

Name of Employer (if applicable) is mandatory

* Required fields

Identification Information

Are you a provider or member? *

Provider

Member

Other

Please select at least one of the items

If you selected other, please enter your title

If you selected other, please enter your title is mandatory

What is your name? *

What is your name? is mandatory

What is your contact information? (phone or email) *

What is your contact information? (phone or email) is mandatory

* Required fields

Appeal, Complaint, or Grievance Details

Claim or Voucher Number

Claim or Voucher Number is mandatory

Date of service (Only leave blank if this is for predetermination of benefits)

Date of service (Only leave blank if this is for predetermination of benefits) is mandatory

Your own description of service(s) being disputed (procedure codes if available): *

This field is mandatory

Reason you're disputing the original processing *

This field is mandatory

What is your desired outcome? *

This field is mandatory

Attach a supporting file

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