Allied

Self-Funded Claim Appeal Notice

Dental Universal Appeal Notice

Federal

Dental Claim Form

State

If you are interested in filing a claim appeal, use the specific forms for your state, if listed. If your state is not listed, please use the ERISA form below to file your appeal.

ERISA Form

Notice of State Claim Appeal Rights

---

Delaware

Delaware External Claim Review Information

​ERISA Form

Notice of State Claim Appeal Rights

---

Georgia

Georgia External, Independent Claim Review Information

ERISA Form

Notice of State Claim Appeal Rights

---

Iowa

Iowa External Claim Review Information

ERISA Form

Notice of State Claim Appeal Rights

---

Kansas

Kansas External, Independent Claim Review Information

ERISA Form

Notice of State Claim Appeal Rights

---

Missouri

Missouri External Claim Review Information

ERISA Form

Notice of State Claim Appeal Rights

---

Nebraska

Nebraska External Claim Review Information

ERISA Form

Notice of State Claim Appeal Rights

---

Ohio

Ohio External Claim Review Information

ERISA Form

Notice of State Claim Appeal Rights

---

South Carolina

South Carolina External Claim Review Information

Medical Records Release

ERISA Form

Notice of State Claim Appeal Rights

---

Texas

Texas External Claim Review Information

Request for a Review by an Independent Review Organization

ERISA Form

Notice of State Claim Appeal Rights

---

Virginia

Virginia External Review Form

ERISA Form

Notice of State Claim Appeal Rights

If you are unable to find what you're looking for, please contact Allied Client Services.