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Please use the form below if you would like to submit additional clinical information that justifies the medical necessity of a denied case. Requests not related to the submission of additional clinical information for a denied case will not be processed if submitted via the form below. Please note that only .PDF and .TIF file types can be supported.
User acknowledges this is a standard request and WILL NOT be processed as expedited regardless of documentation attached or additional information/notes submitted with this form. Additionally, User acknowledges to being informed of the appropriate method of EXPEDITED submission of an additional information on a denied case.
Expedited cannot be completed online at this time. For expedited submission of information to a Denied case, please call 800-792-8744, option 4.