Request for Appeal of Medical Coverage Denial

For Leon Medical Centers Health Plans members

Because we denied your request for coverage of (or payment for) medical care, you have the right to ask us for an appeal of our decision. You have 60 days from the date of our Notice of Denial of Medical Coverage to ask us for an appeal.

Who May Make a Request: You or your doctor may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. You may download and complete the Appointment of Representative Form.

Enrollee's Information
First Name:  
Last Name:  
Date of Birth:      (i.e. 06/04/1776 mm/dd/yyyy)
Plan ID Number:  
Street Address:  
State:      (i.e. FL)
Zip Code:      (i.e. [33166]-0000)
Enrollee Phone:      (i.e. 305-559-5366)
Complete the following section ONLY if the person making this request is not enrollee:
Requestor Name:
Relationship to Enrollee:
Street Address:
State:  (i.e. FL)
Zip Code:  (i.e. [33166]-0000)
Requestor Phone:  (i.e. 305-559-5366)

Note: You will need to mail or fax separately the documentation showing the authority to represent the Enrollee (a competed Appointment of Representative Form CMS-1696 or a written equivalent) if it was not submitted at the organization determination level. For more information on appointment a representative, contact our plan or 1-800-Medicare.

Medical Coverage you are requesting:
Service Requested:  

Have you already received the medical care?
If "Yes"

Date of Service:    (i.e. 06/04/1776 mm/dd/yyyy)
Amount Paid:  
Provider's Information
Provider Name:  
Street Address:  
State:      (i.e. FL)
Zip Code:      (i.e. [33166]-0000)
Office Phone:    (i.e. 305-559-5366)
Office Fax:  (i.e. 305-559-5366)
Office Contact Person:
Important Note: Expedited Decisions

If you or your doctor believe that waiting 30 days for a standard decision could seriously harm your life, health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your doctor indicates that waiting 30 days could seriously harm your heath, we will automatically give you a decision within 72 hours. If you do not obtain your doctor’s support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a medical care you already received.

Check this box if you believe you need a decision within 72 hours.

Please explain your reasons for appealing. You may want to refer to the explanation we provided in the Notice of Denial of Medical Coverage.
Reason for Appeal: